Varicose Veins

  1. 2. Race*
    BlackAsianHispanicWhiteOther
  2. 6. Do you have a history of Varicose Veins in your family? *
    YesNo
  3. 7. Have you been pregnant in the last 2 years?*
    YesNoDoes not apply
  4. 8. Do your daily activities consist of long periods of sitting or standing?*
    YesNo
  5. 9. Have you recently suffered trauma to your legs?*
    YesNo
  6. 10. Have you noticed changes in skin color around your ankles or legs?*
    YesNo
  7. 11. Do you feel heaviness, fullness, aching or pain in your legs?*
    YesNo
  8. 12. Have you noticed skin sores (ulcers) on your legs?*
    YesNo

Book an appointment
Center is open from 8 AM - 5 PM on Mon - Fr
281-949-6020 office@coastalvascular.net
Same and next day appointments available!
Same and next day appointments available!