Self Assessment Test The following self assessment will help determine if you may benefit from a minimally invasive treatment from Milligan Vein. Please fill out the fields below and we will contact you shortly. Thank you! Step 1 of 3 – Basic Information and Medical History 0% EmailThis field is for validation purposes and should be left unchanged.Date of Birth(Required) Month Day Year Gender(Required) Male Female Local Zip Code(Required)Do you have leg pain?(Required) None Occasionally Daily Limits Activity Do you have swelling of the ankle or leg?(Required) None By Morning By Afternoon By Evening Do you have visible varicose veins?(Required) Yes No Have you had major surgery lasting over an hour in the last month?(Required) Yes No Are you pregnant or had a baby within the last month?(Required) Yes No In the past month, if you have felt pain in the legs, what was the intensity of this pain?(Required) No Pain Light Pain Moderate Pain Strong Pain Intense Pain Using the images below as a reference, please check the condition(s) below that correspond to the condition of your legs. No visible signs of venous disease Spider veins, reticular veins, malleolar flare Varicose veins Swelling without skin changes Chronic skin changes (pigmentation, eczema, thickened skin) Chronic skin changes with healed ulceration Chronic skin changes with active ulceration First Name(Required)Last Name(Required)Phone Number(Required)Email(Required) Disclaimer Agreement:(Required) I agree. Milligan Vein respects the privacy of its patients and website visitors. Our website collects names, email addresses, and other personal information when submitted via one of our online forms. However, this data is used solely by Milligan Vein and is not shared, traded, or sold to third parties.I understand that Milligan Vein cannot guarantee privacy for e-mail communications over the internet, other than website submissions from their official website, www.milliganvein.com. I understand and accept this risk, and thus, will allow Milligan Vein to communicate my protected health information using my personal e-mail address listed above.Help us stop spam bots: Δ
