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General Information

Please fill out this brief questionnaire to assist us in providing you with the best care possible.

Check all that apply.

Do you have pain, cramping, aching, numbness, tiredness, weakness, or burning in your buttock, thigh, calf or foot?
Do you have restless legs?
Do you have numbness in your legs or feet?
Does your skin appear pale and feel cool to the touch?
Do you have foot or toe pain or tingling that does not go away with rest?
Do you have a feeling that hip or leg is "giving out" while walking?
Do you have skin wounds, sores, infections or ulcers on your legs or feet that heals slowly or don't heal at all?
Do you have swelling of ankles or lower legs?
Do you have heavy, tight, or achy legs?
Do you have skin that becomes discolored, feels leathery, flaky and/or itchy?
Do you have chest pain?
Do you have shortness of breath?

What's On Your Mind?

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