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Initials only
*
Contact email
*
Contact telephone number
*
Swelling of the legs or ankles (edema)
*
no
yes
Pain in your legs that worsens when you stand or walk and gets better when you raise your legs
*
no
yes
Leg cramps
*
no
yes
Aching, throbbing, or a feeling of heaviness in your legs
*
no
yes
Itching and burning sensations in legs
*
no
yes
Thickening of the skin on your legs or ankles
*
no
yes
Skin discoloration, especially around the ankles
*
no
yes
Leg ulcers
*
no
yes
Visible varicose veins (SEND PHOTO PLEASE)
*
no
yes
Restless legs or leg cramps especially at night
*
no
yes
Please attach up to 6 photos labeled right or left leg or a short video of the parts of your legs with skin changes or varicose veins troubling you
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