Online Screening

Signs & Symptoms

Do you experience any of the following in your legs? (Mark all that apply)

Pain
Aching
Cramping
Itching
Heaviness
Tiredness
Restlessness when sleeping

Do you have visible, stretched or swollen veins?

Do you have blue, black and green areas of discoloration?

Do you have pain, burning or discomfort at different times of the day? (Mark all that apply)

Yes, my veins are worse late in the day.
Yes, my veins are worse during hot weather.
Yes, my veins are worse after exercise or strenuous activity.
No, my symptoms are consistent throughout the day.

Background & Risk Factors

Have You Been Pregnant?

How long ago?

Do you have a family history of varicose veins, or family members who have been diagnosed with venous reflux, venous insufficiency or blood clots?

Does your job or hobby cause you to be inactive, specifically standing or sitting for long periods?

Have you ever been diagnosed with or treated for a vein disorder?

Submit A Photo

If you’d like, please submit two photos - one of the side and one of the back of your leg - showing the veins you are most concerned about. Photos are not required to complete the assessment.

File Upload

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

Personal Information

Name *

First

Last

Age

Gender

Male
Female

Phone Number

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Disclaimer: I understand that this online screening is a preliminary survey of visible veins and symptoms to determine the likelihood of vein disease and/or varicose veins, and does not constitute a definitive diagnosis of vein disease, varicose veins or any other disorder. I hereby release the physician, certified registered nurse practitioner and healthcare providers of Advanced Vein Care of Altoona of any and all responsibility with regard to this online screening. I understand that a definitive diagnosis of vein disease, varicose veins, blood clots or any related condition can only be performed with an in-person, in-office screening.

Welcome to AVC’s online screening

Signs & Symptoms

Background & Risk Factors

Submit A Photo

Personal Information