PAD Consult Request for MSP

1
Do you experience discomfort while walking?
YESNO
2
Do you experience pain walking 5 blocks without stopping?
YESNO
3
Do you find yourself sitting up to dangle your legs off the edge of the couch or bed to relieve discomfort you may be experiencing at rest?
YESNO
4
Do you experience foot or toe pain that often disturbs your sleep?
YESNO
5
Are your toes or feet pale, discolored, or bluish?
YESNO
6
Do you have skin wounds or ulcers on your feet or toes?
YESNO
7
Has your doctor ever told you that you have diminished or absent pedal (foot) pulse?
YESNO
8
Have you ever had vascular surgery on your leg(s)?
YESNO
9
Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)?
YESNO
10
Have you experienced hair loss below the knee over time?
YESNO
11
Are your feet always cold? Or have you noticed that one foot may seem to always feel colder than the other?
YESNO
12
Do you have Diabetes, High Blood Pressure, or High Cholesterol?
Diabetes
High Cholesterol
High Blood Pressure
None
13
Your Risk Factor Score
14
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Bel Air, MD
Elkton, MD
White Marsh, MD
Culpeper, VA
Haymarket, VA
Manassas, VA
Strasburg, VA (Opening Soon!)
Midlothian, VA
Petersburg, VA
Chesapeake, VA
Norfolk, VA
Virginia Beach, VA
Location
15
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