Has your pelvic/abdominal symptoms last 6 months or longer?
Select the option that applies using the DROP DOWN MENU BELOW
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6 months or greater
Less than 6 months
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Are these signs or symptoms visible on your body? Select all that apply
See the photos below as references. Use checkbox not photos to select all that apply.
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Varicose Veins (bulging veins)
Spider Veins
Heavy Legs
Ulcers (open sores)
Leg Swelling
Discoloration
None of the above
Do you have pelvic or abdominal pain during or after sexual intercourse?
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Yes
No
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On a scale of 1-10, How severe would you rate your abdominal/pelvic symptoms? (10 being excruciating pain)
Select Pain Level
1-2 (occasional)
3-4 (very mild)
5-6 (mild)
7-8 (severe)
9-10 (very severe)
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What solutions have you tried in the past (*If ANY)?
Select all that apply.
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Prescription Medication
Compression Therapy
ObGYN (Gynecologist)
Other Specialist
Nothing Yet
Other Solution
Does any of the following apply to you?
Select all the applies.
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Pelvic heaviness or fullness, worse after prolonged sitting or standing
High-degree of discomfort during menstration
Vaginal swelling
Multiple pregnancies
Overweight
Family history of vascular disorder
None of the above applies
We'd love to schedule a follow-up since you're experiencing discomfort and show signs of chronic pelvic of a vascular origin. Fill out the fields below and a representative will contact you.
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Last Name
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Date of birth
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