Full Name
*
Date of birth
Cell Phone
*
Email
*
Do you notice your legs feel fatigues, tired, achy, or swell?
*
Yes
No
Especially in the evening?
*
Yes
No
Do you have visible varicose or spider veins?
*
Yes
No
Do you notice that your socks leave an impression on your skin at the end of the day?
*
Yes
No
Have you lost hair growth in the bottom half of your legs?
*
Yes
No
Have you experienced restless legs or leg cramping?
*
Yes
No
In the last four weeks, have your legs symptoms interrupted: (check all that apply)
*
Sleep
Doing an activity that requires walking/sitting
Traveling
Other
None of these apply
Have you consulted a physician for these symptoms yet?
*
Yes
No
Submit
