Brookhaven Heart Virtual Vein Screening

Over 30 million Americans suffer from venous disease, one of the most serious forms being chronic venous insufficiency (CVI). CVI occurs when valve damage in the leg veins effects blood flow to the heart from the legs, causing blood to "pool" in these veins. Valve damage may occur as a result of aging, extended sitting or standing, pregnancy and obesity. Symptoms include varicose veins, night cramps, leg/ankle swelling, tight calves, and legs that feel heavy, tired, restless, or achy1.

Please answer the questions below to help us determine if you are at risk for CVI and if a consultation would help us better assess your vascular health status.

First Name:

Last Name:
E-mail Address:
Phone:
   
What symptoms are you experiencing?
Check all that apply.
Heavy or tired legs
Painful legs
Leg swelling or throbbing
Leg restlessness
Leg numbness
Itching or burning sensations in your legs
Cramping of legs (especially at night)
Do you have varicose veins (veins that are enlarged or swollen and raised above the surface of your skin) in your legs?
Yes
No
Attach a picture of your legs
Using your smartphone, tablet, or digital camera, please attach a full picture of the front and back of your leg (1 photo per side)
Before After   Before After   Before After   Before After
     
Before After   Before After
 
 
Before After
  The following is a form that can be used to communicate with the physician you have researched on VenaCure EVLT.

Use of this form to communicate with a physician is solely at your discretion. Neither Body1, Inc. nor its sponsors handles or collects information that is provided to physicians through the use of this form. Please be advised that if you email this form to a physician, you are sending this form over the Internet without privacy encryption.

1. Overview V. Varicose veins: Overview. Ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK279247/. Published 2019. Accessed May 30, 2019.