PAD Risk Form

1

Full Name

First Name

Last Name

2

Birth Date

Date

3

Phone Number

Area Code

Phone Number

4

Email

example@example.com

5

Are you 50 years or older?* This field is required.

YESNO

6

Do you smoke or have you ever smoked?* This field is required.

YESNO

7

Have you ever been diagnosed with any of the following

Diabetes

High Blood Pressure

Chronic Kidney Disease

High Cholesterol

8

Do you have a family history of PAD(peripheral arterial disease)?

YESNO

9

Have you ever been diagnosed with PAD, Heart Disease or Stroke?

YESNO

10

Do you ever experience tiredness, heaviness or cramping in the leg muscles, especially during activity?* This field is required.

YESNO

11

When you inspect your toes and feet, do they look pale, discolored or bluish?* This field is required.

YESNO

12

If you have leg pain, does it disturb your sleep?

YESNO

13

Does one leg or foot regularly feel colder than the other?* This field is required.

YESNO

14

Have you experienced sores or wounds on the toes, feet or legs that heal slowly or not at all?* This field is required.

YESNO

15

Have you noticed poor nail growth and decreased hair growth over time on the toes and legs question?* This field is required.

YESNO