Colorado Skin & Vein Virtual Consultant

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Vascular Virtual Consult

Vascular Virtual Consult

Step 1 of 44

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1Basic Information

Let’s begin by capturing a little information about you.

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2Name(Required)

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3Phone(Required)

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4Email(Required)

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5Privacy(Required)

I have read and agree to the Privacy Policy linked here.

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6Section 1: Symptoms

Please answer as honestly as possible. We need the facts to figure out how we can help!

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7Do your legs ever get tired or painful?(Required)

Yes

No

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8Do your legs ever get tired or painful? drop down example(Required)

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9Do they feel worse with long periods of sitting, standing or at the end of the day?(Required)

Yes

No

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10Do your legs ever feel heavy, sore or tired?(Required)

Yes

No

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11Do your legs feel bad after long air travel?(Required)

Yes

No

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12Do your ankles, calves or legs ever swell?(Required)

Yes

No

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13Which image best matches your ankle, calf or leg swelling?(Required)

a. Mild swelling picture

b. Medium swelling picture

c. Severe swelling picture

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14Does the swelling get better with compression?(Required)

Yes

No

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15Do you ever have night time calf or foot cramps?(Required)

Yes

No

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16How often do you experience nighttime calf or foot cramps?(Required)

a. Once a month

b. Once a week

c. Several times a week

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17Do they ever wake you from sleep or require that you walk around for relief?(Required)

Yes

No

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18Do you ever feel the need to shuffle your legs after going to bed to get comfortable?(Required)

Yes

No

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19Does this affect your sleep?(Required)

Yes

No

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20How often do you experience these symptoms?(Required)

a. Once a month

b. Once a week

c. Several times a week

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21Do you ever experience itching or burning in your legs?(Required)

Yes

No

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222. Signs

Varicose veins are enlarged, twisted veins that often appear on the legs and feet. They occur due to weakened or damaged valves in the veins, leading to blood pooling and increased pressure within the veins.

Let’s see if we can learn a little more about your condition.

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23Do you have visible veins?(Required)

Yes

No

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24Would you like to share a picture with me?(Required)

This will greatly aid us in determining your treatment needs.

Yes

No

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25Please upload your picture(Required)

Max. file size: 128 MB.

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26Can you tell me where the veins are located?(Required)

Upper body

Lower body

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27Can you choose all the pictures with resemble the veins that you see?(Required)

a. Facial telangiectasia picture

b. Facial reticular vein picture

c. Rosacea picture

d. Port Wine Stain Picture

e. Chest reticular vein picture

f. Cherry Angioma picture

g. Venous Lake Picture

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28Can you choose all the pictures with resemble the veins that you see?

a. Leg telangiectasia picture (ankle, knee, thigh)

b. Venectasia picture

c. Corona picture

d. Varicose vein picture

e. Something different

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29Do you have any discoloration over your lower legs?(Required)

Yes

No

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30Which of these pictures best resembles the discoloration?

a. Pictures of hemosiderin staining

b. Venous statis picture

c. Lipodermatosclerosis picture

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31Do you have any open or healed wounds over your lower legs?(Required)

Yes

No

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32Can you send me a picture of this area?(Required)

Yes

No

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33Please upload you picture here

Max. file size: 128 MB.

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34Can you tell me which picture most closely resembles the lesions? (Please add a web link for reference)

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353. Health History

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36Have you ever had any vein treatments before?(Required)

Yes

No

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37Can you please tell me which treatments you have had?

Sclerotherapy

Endovenous laser or radio frequency ablation

Vein stripping

Varithena

VenaSeal

Superficial laser treatments for cosmetic reasons

Something else

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38Have you or any of your immediate family members had previous clots or been told you are may clot easily?(Required)

Yes

No

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39Would you like us to see if your insurance covers procedures related to this diagnosis?(Required)

Yes

No

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40Please upload insurance card here

If you do not have insurance, please leave this field blank.

Max. file size: 128 MB.

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41What is your prefered platform for communication?(Required)

Phone call

Text

Email

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42Do you want a scheduled follow up?(Required)

Yes

No

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43Preferred day and time(Required)

Following your submission of this form, a representative will be in touch via your preferred method of communication, to schedule your visit!

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Thank you for taking the survey!
Please submit to learn more about how Colorado Skin & Vein can help you!

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