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Vascular Screening Survey

Step 1: Complete 3 Minute Vein Screening and hit “Send” at the bottom of the page.

Step 2: A team member will call you within 48 hours (2 business days) to discuss your vein screening results. If we miss you, a detailed email will be sent providing you with your results.

    Have you ever had spider veins or varicose veins? *

    Do you experience or suffer from any of the following signs or symptoms in your legs?

    Has anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease?*

    Do you stand for prolonged periods of time? *

    Have you had any treatments or procedures for vein problems? *

    Have you ever had surgery to your veins in your legs, vein removal for open heart surgery, vein stripping in your legs, or cosmetic vein repair? *

    Have you ever had a test on your legs (blood pressure cuffs on your ankles) sometimes called a PVR?*

    Have you ever had a venous sonogram (also called venous Doppler)? *

    Have you ever had a venous ultrasound (also called venous Doppler)? *

    Do you have any risk factors listed below? *

    Do you have noticeable distended veins: *

    Do you have Diabetes? *

    Have you ever had a blood clot in your legs (DVT or Deep Vein Thrombosis): *

    Does your job or daily activity require standing for long periods of time: *

    Date of Birth

    Premier Vascular Image
    Premier Vascular, Yonkers, NY
    125 Corporate Blvd, Suite 307, Yonkers, NY 10701
    Premier Vascular, Jackson Heights, NY
    37-12 92nd Street, 2nd Floor, Jackson Heights, NY 11372
    Premier Vascular, Brooklyn, NY

    765 Nostrand Avenue, 3rd floor, Brooklyn, NY. 11216

    Phone (appointments): 718-355-9754
    Phone (appointments):

    Fax: 718-894-0164

    Phone (appointments):


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