Welcome to Advanced Regenerative Health's Vein Quiz!
Please answer these brief questions to the best of your ability to help us determine if our services could be right for you.
First Name
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Last Name
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Phone
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Email
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City
Primary Insurance
Secondary Insurance
Primary Concern
What is the main reason you want a vein consultation? (Choose any that apply)
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Varicose veins (bulging/raised veins)
Spider veins (small red/blue/purple veins)
Leg swelling (ankle/foot/leg)
Leg pain/aching/heaviness
Skin discoloration/staining near ankle/lower leg
Numbness/tingling/burning sensations
Non-healing sore/ulcer near ankle/lower leg
Other
Please explain
Which symptoms are you experiencing? (Select all that apply)
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Aching/throbbing pain
Heaviness or tired legs
Swelling in ankles/feet/legs
Cramping (especially at night)
Itching over/around veins
Burning sensation
Restless legs
Numbness/tingling
Visible bulging veins
Spider veins (red/blue/purple)
Skin discoloration (brown/red staining)
Hard/thickened skin near ankle
Open sore/ulcer or slow-healing wound
Bleeding from a vein
None of the above
Where are you experiencing symptoms? (Select all that apply)
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Right leg
Left leg
Both legs
Ankles/feet
Calves
Thighs
Behind the knee
Not sure
How long have you had these symptoms/vein concerns?
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Less than 1 month
1–3 months
3–6 months
6–12 months
1–3 years
3+ years
How much do your symptoms affect your daily life?
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Mild (mostly cosmetic or occasional discomfort)
Moderate (regular discomfort; sometimes limits activity)
Severe (frequent pain/swelling; limits activity or sleep)
Which statements describe your symptoms? (Select all that apply)
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Worse after standing for long periods
Worse after sitting for long periods
Worse by the end of the day
Better when I elevate my legs
Better when I walk or move around
Compression stockings help
Nothing helps / not sure
Have you had any of the following? (Select all that apply)
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Prior diagnosis of venous insufficiency / reflux
Prior vein treatment (ablation, sclerotherapy, phlebectomy, etc.)
Current open sore/ulcer on lower leg/ankle
Bleeding from a vein (spontaneous or after minor bump)
History of blood clot (DVT) or pulmonary embolism
Skin hardening/thickening near ankle (advanced skin changes)
None of the above
Have you tried any conservative treatments for your vein symptoms? (Select all that apply)
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Compression stockings
Leg elevation
Regular walking/exercise
Weight loss (if applicable)
Anti-inflammatory meds (e.g., ibuprofen/naproxen) if allowed
I tried conservative treatment for 6+ weeks
I have not tried conservative treatment yet
Not sure