To find out if the radiofrequency VNUS Closure^® procedure may be appropriate for you, please complete our short questionnaire.

1. Have you previously been diagnosed with venous reflux or venous insufficiency?	No Yes
2. Do you have varicose veins? (Varicose veins are large, blue, bulging veins as opposed to spider veins, which are small, thin veins that lay close to the skin surface.)	No Yes
3. Do you experience any of the following symptoms? Leg pain, aching or cramping Burning or itching of the skin Leg or ankle swelling "Heavy" feeling in legs Skin discolorations or texture changes Open wounds or sores	No Yes
4. Has anyone in your blood related family been diagnosed with varicose veins?	No Yes
5. Has anyone in your blood related family had vein stripping?	No Yes
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