Circulation Self Assessment Quiz

First name*

Last name*

Zip code*

Contact number

Phone

Email*

Do you experience any pain at rest in your leg(s) or feet?

Yes

No

Do you have ANY foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping, restless legs or pain) when walking or sitting that is relieved by rest or leg elevation?

Yes

No

Are your toes, feet and/or calf areas pale, discolored or bluish?

Yes

No

Do you have an infection, skin wound or ulcer on your feet, toes or leg(s) that is not healing (8-12 weeks)?

Yes

No

Do you have coronary artery disease (blockages in the heart)?

Yes

No

Do you have bulging varicose veins on your legs?

Yes

No