Patient Information

First Name:

Last Name:

Contact Email:

Contact Phone:

Today's Date:

Date of Last Operation:

Medical Information

Doctor: --Select-- Dr. Dale Maharaj Not seen a doctor yet Other

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Surgery Type: --Select-- Laser Treatment Sclerotherapy Vein Stripping Ambulatory Phlebectomy Endovenous Thermal Ablation Compression Therapy

HASTI Symptoms

Heaviness: (Feeling of heaviness in the legs)

3

Low High

Achiness: (Persistent dull pain or discomfort)

3

Low High

Swelling: (Visible or physical swelling in the legs)

3

Low High

Throbbing: (Rhythmic pulsating sensation)

3

Low High

Itching: (Irritation or itching in the affected area)

3

Low High

Additional Information

Upload an image of the affected area:

Would you like to be contacted? --Select-- Yes, I would like a consultation Yes, I need immediate attention No, Just updating my diary

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