Virtual Vein Screening


The following form will help determine if you may benefit from a vein or vascular treatment from Siragusa Vein & Vascular Center of Nashville.

"*" indicates required fields

Step 1 of 2 - Basic Information and Medical History

Date of Birth*
Gender*
Do you have leg pain?*
Do you have swelling of the ankle or leg?*
Do you have visible varicose veins?*
Have you had major surgery lasting over an hour in the last month?*
Are you pregnant or had a baby within the last month?*
In the past month, if you have felt pain in the legs, what was the intensity of this pain?*
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Using the images below as a reference, please check the condition below that correspond to the condition of your legs.