Self Assessment

Date of Birth*
MM
DD
YYYY
Gender*
- Male
- Female
Local Zip Code*
Do you have leg pain?*
- None
- Occasionally
- Daily
- Limits Activity
Do you have swelling of the ankle or leg?*
- None
- By Morning
- By Afternoon
- By Evening
Do you have visible varicose veins?*
- Yes
- No
Have you had major surgery lasting over an hour in the last month?*
- Yes
- No
Are you pregnant or had a baby within the last month?*
- Yes
- No
In the past month, if you have felt pain in the legs, what was the intensity of this pain?*
- No Pain
- Light Pain
- Moderate Pain
- Strong Pain
- Intense Pain

First Name*
Last Name*
Phone Number*
Email*
Disclaimer Agreement:*
- 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.
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