Shapiro Vein Center Safely and securely send photos to your doctor’s office so you can perform a self-assessment from the comfort and privacy of your home! Step 1 of 4 25% Practice Email Step 1 Contact InformationName*Date of Birth* Phone*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Step 2 Patient Assessment QuestionsLeg pain, aching or crampingYesNoBurning or itching of the skinYesNo“Heavy” feeling in legsYesNoVisible varicose or spider veinsYesNoLeg or ankle swelling, especially at the end of the dayYesNoSkin discoloration or texture changes, such as above the inner ankleYesNoOpen wounds or sores, such as above the inner ankleYesNoRestless Leg SyndromeYesNoOther (fill in the field below) Step 3 Patient Risk FactorsHas anyone in your blood-related family had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?YesNoHave you had any treatments or procedures for vein problems?YesNoDo you stand for long periods of time, such as at work?YesNoDo you frequently engage in heavy lifting?YesNoHave you ever been pregnant?YesNo Step 4 Upload Photo(s) Please provide a full front and a back photo (1 each) in natural light with your smart phone, tablet, or quality digital camera, of your entire leg(s), and then upload the files to the formPhotos Drop files here or Accepted file types: jpg, jpeg, gif, png, mov.
