• Pad-Survey

  • Patient Questionnaire for Symptoms Suggestive of Autonomic Dysfunction:

  • Do you have diabetes?*
  • Have you had low blood sugar (with our without fainting) and not been aware of it?*
  • Do you sweat when you cat, even if the food is not spicy, or do you have dry skin on your hands or feet?*
  • Do you have _______ in your feet? Check which symptom(s) you have*
  • Do the bedsheets or your socks bother or hurt your feet?*
  • Do you have _______ in your hand? Check which symptom(s) you have*
  • Do you have trouble driving or seeing at night?*
  • Do you feel dizzy or faint when you stand up too quickly?*
  • Do you feel bloated or full after the first few bites of food?*
  • Do you get tired as soon as you start to exercise?*
  • Do you have diarrhea at night?*
  • Do you have urinary incontinence?*
  • Men only: do you have difficulty with erections that has not improved with medications like Viagra or Cialis?*

  • American Heart Association Pad-Survey

    Answers to the following questions will help determine if you are at risk for Peripheral Arterial Disease (PAD) and if a vascular examination can help better assess your voscular health status.

  • Do you experience any pain in your legs or feet while at rest?*
  • Do you have uncomfortable aching, fatigue, tingling, cramping or pain in your feet, calves, buttocks, hip or thigh during walking/exercise?*
  • Does the pain go away when you stop walking/ exercising?*
  • Do your feet get pale, discolored or bluish at any time during the day?*
  • Do you have an infection, skin wound or ulcer on your leg or foot that is slow to heal over the past 8-12 weeks?*
  • Do you have high cholesterol or other blood lipid (fat) problems or require cholesterol medication?*
  • Do you have high blood pressure or take medication to reduce blood pressure?*
  • Do you have diabetes?*
  • Do you have a history of chronic kidney disease?*
  • Do you currently or have you ever smoked?*
  • Do you have a history of stroke or mini-stroke (TIA)?*
  • Do you have a history of heart disease (heart attack, MI)?*
  • Do you have a history of carotid stenosis, AA (abdominal aortic aneurysm), and/ or stent placement?*

  • Neuropathy-Questionnaire

  • Patient Questionnaire for Symptoms suggestive of Autonomic Dysfunction:

  • 1. Do you have diabetes?*
  • 2. Have you had low blood sugar (with our without fainting) and not been aware of it?*
  • 3. Do you sweat when you eat, even if the food is not spicy, or do you have dry skin on your hands or feet?*
  • 4. Do you have pain, tingling, burning, numbness, or electrical shocks in your feet. ?*
  • 5. Do the bedsheats or your socks bother or hurt your feet ?*
  • 6. Do you have pain, tingling. burning, numbness, or electrical shocks in your hands ?*
  • 7. Do you have trouble driving or seeing at nigh ?*
  • 8. Do you feel dizzy or faint when you stand up too quickly?*
  • 9. Do you feel bloated or full after the first few bites of food'?*
  • 10. Do you get tired as soon as you start to exercise ?*
  • 11. Do you have diarrhea at night?*
  • 12. Do you have urinary incontinence?*
  • 13. Men only: do you have difficulty with erections that has not improved with medications like Viagra or Cialis?
  • Should be Empty: