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Have you ever been diagnosed with any vein related disorders?
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Has anyone in your biological blood-related family ever had varicose veins or been diagnosed with venous disease?
YesNo

Do you stand for prolonged periods of time?
YesNo

Do you experience or suffer from any of the following signs or symptoms in your legs? (Check all that apply)
Leg HeavinessRestless LegsItching on the SkinLeg or Ankle SwellingLeg PainSkin DiscolorationVenous Ulcers

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