Welcome to the Ozark Regional Vein & Artery Center. What is your name?

Nice to meet you. We’re glad you’re here!

Are you filling this questionnaire out for yourself or a loved one?

If you're filling this out on behalf of someone else, have their information readily available.

What is your date of birth?

We’re going to ask you a few questions to help identify your vascular health concerns. Don’t worry, this should only take 5 minutes.

We’re going to ask you a few questions to help identify your loved one’s vascular health concerns. Don’t worry, this should only take 5 minutes.

Are you experiencing recurring leg pain, cramps, or muscle soreness that have worsened over time?

Are they experiencing recurring leg pain, cramps, or muscle soreness that have worsened over time?

When do you usually experience this physical discomfort? Select all that apply.

When do they usually experience this physical discomfort? Select all that apply.

How would you rate your pain on a scale of 1-10?

How would they rate their pain on a scale of 1-10?

Do you have a family history of vascular disease or blood clots?

Does their have a family history of vascular disease or blood clots?

Have you received any prior vein or arterial treatments?

Have they received any prior vein or arterial treatments?

Do you currently take any medications for cholesterol or blood pressure?

Do they currently take any medications for cholesterol or blood pressure?

Are you experiencing any of these symptoms? Select all that apply.

Are they experiencing any of these symptoms? Select all that apply.

Final question: Will you be covering all or part of your treatment with insurance/Medicare?

Final question: Will they be covering all or part of their treatment with insurance/Medicare?

Alrighty, almost done! Now we just need to know how to reach you.

Alrighty, almost done! Now we just need to know how to reach them.

If you have any other additional necessary comments, please leave them here!