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507-322-6900
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Peripheral Artery Disease
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Restless Legs Syndrome
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Virtual Vein Screening
Patient Provides contact information
Patient Assesment Question
Do you experience any of the following signs and symptoms in your legs or ankles
Leg pain itching and cramping
Yes
No
Burning and itching of the skin
Yes
No
Havey Felling in legs
Yes
No
Leg or ankels swelling ,espically at the end of the day
Yes
No
Visible varicose or spider venis
Yes
No
Skin discolration or texture changes ,such as above the inner ankle
Yes
No
Open wounds or sores ,such as above the inner ankles restless leg syndroms
Yes
No
Patient Risk Factors
Has anyone in your blood-related family had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?
Yes
No
Have you had any treatments or procedures for vein problems?
Yes
No
Do you stand for long periods of time, such as at work?
Yes
No
Do you frequently engage in heavy lifting?
Yes
No
Have you ever been pregnant?
Yes
No
Take Photo(s)
Patients sends Photos To your office via VSA’s HIPPA Compliant Server
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JRK Medicals
LOCATION
2633 Superior Drive NW Suite 100 Rochester MN 55901
507-322-6900
LOCATION
1515 St. Francis Ave, STE 250, Shakopee MN, 55379
507-361-1218
507-322-6967
contact@jrkmedicals.com
Schedule a consultation
Worried about your vascular and vein problem? Experience JRK Medicals
507-322-6967 