Are You a Candidate for Endovenous Ablation?
Ace Vein & Wellness
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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1. What symptoms do you experience most frequently?
A Visible, bulging veins in my legs
B Aching or heavy feeling in my legs, especially after standing
C Swelling in my legs, ankles, or feet
D Throbbing, cramping, or itching around my veins
E Skin discoloration or ulcers near my ankles
F None of the above
1A
1B
1C
1D
1E
2. How long have you been experiencing these symptoms?
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A Less than 6 months
B 6 months to 1 year
C 1 to 2 years
D Over 2 years
2A
2B
2C
2D
2E
3. Have you tried any of the following treatments for your varicose veins?
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A Compression stockings
B Over-the-counter pain relief
C Lifestyle changes (e.g., exercise, diet)
D Other medical procedures (e.g., sclerotherapy)
E None of the above
3A
3B
3C
3D
3E
4. How would you describe your overall health?
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A Excellent – I’m in great shape with no significant health issues.
B Good – I have minor health concerns but nothing serious.
C Fair – I have a few ongoing health issues.
D Poor – I have significant health challenge tos.
4A
4B
4C
4D
5. Have you been diagnosed with any of the following conditions?
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A Deep vein thrombosis (DVT)
B Chronic venous insufficiency
C Diabetes
D heart disease
E None of the above
5A
5B
5C
5D
5E
6. What is your primary goal in seeking treatment for varicose veins?
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A Improve the appearance of my legs
B Reduce pain and discomfort
C Prevent the condition from worsening
D Improve overall circulation and leg health
E All of the above
6A
6B
6C
6D
6E
7. Have you undergone any surgical procedures in the past 6 months?
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Yes
No
7A
7B
8. Are you concerned about the recovery time after the procedure?
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A Yes, I need to return to normal activities quickly.
B Somewhat, but I can take time off if necessary.
C No, I’m prepared for a recovery period if needed.
8A
8B
8C
9. How did you hear about endovenous ablation?
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A Doctor’s recommendation
B Friend or family member
C Online research
D Advertisement
E Other
9A
9B
9C
9D
9E
A TOTAL
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B TOTAL
C TOTAL
D TOTAL
E TOTAL
HIGHEST
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