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Home
Medical Team
Vein Disease
What Is Vein Disease
Self Assessment
Procedures
Radiofrequency Ablation
Varithena
VenaSeal
EVLT (Endovenous Laser Treatment)
Ultrasound Guided Sclerotherapy
Phlebectomy
Vein Stripping
Patients
Before & After Gallery
History & Physical Form
Media
Patient Testimonials
Patient Education
News
Locations
Knoxville
Crossville
Morristown
Johnson City
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Self Assessment
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Self Assessment
Self Assessment
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%
Date of Birth
*
Month
Day
Year
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
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
*
Last Name
*
Phone Number
*
Email
*
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