PAD Questionnaire

Peripheral Arterial Disease (PAD) is a serious circulatory problem in which the blood vessels that carry blood to your arms, legs, brain or kidneys become narrowed or clogged. It affects over 8 million Americans, most over the age of 50. It may result in leg discomfort with walking, poor healing of leg sores/ulcers, difficult to control blood pressure, or symptoms of stroke. People with PAD are at significantly increased risk for stroke and heart attack. Answers to these questions will determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.

First Name (*)

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Last Name (*)

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Phone (*)

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Email

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Select “Yes” or “No”:

Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest?

Yes No Invalid Input

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

Yes No Invalid Input

Do you experience foot or toe pain that often disturbs your sleep?

Yes No Invalid Input

Are your toes or feet pale, discolored, or bluish?

Yes No Invalid Input

Do you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks)?

Yes No Invalid Input

Has your doctor ever told you that you have diminished or absent pedal (foot) pulses?

Yes No Invalid Input

Have you suffered a severe injury to the leg(s) or feet?

Yes No Invalid Input

Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)?

Yes No Invalid Input

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Electronic Signature(*)

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