1. Do you have varicose veins? (Varicose veins are large, bulging veins as
     opposed to spider veins, which are thin, branching veins that lie just
     beneath the skin surface.)

2. Do you experience any of the following symptoms in your legs, ankles, or feet?

        Leg pain, aching or cramping

        Burning or itching of the skin

        Leg or ankle swelling

        "Heavy" feeling in legs

        Skin discolorations or texture changes, such as above the inner ankle

        Open wounds or sores, such as above the inner ankle

        Restless Legs

3. Does anyone in your blood related family have varicose veins or been     diagnosed with venous reflux?

4. Have you had any treatments or procedures for your vein problems?

5. Has anyone in your blood related family had vein stripping?

6. Do you stand for long periods of time, such as at work?

7. Do you frequently engage in heavy lifting?

8. Have you had multiple pregnancies?