PAD Consult Request for MSP

1

Do you experience leg pain or cramping during walking that eases with rest? (Claudication)

YESNO

2

Have you noticed hair loss or decreased hair growth on your lower legs or feet?

YESNO

3

Do you need to elevate or dangle your legs to relieve discomfort when resting?

YESNO

4

Do you have persistent foot or toe pain that wakes you at night?

YESNO

5

Are your toes or feet pale, bluish, or cold to the touch?

YESNO

6

Do you have any non-healing wounds, ulcers, or sores on your feet or toes?

YESNO

7

Has a healthcare provider ever told you your foot pulses are weak or absent?

YESNO

8

Have you had any vascular surgery or procedures on your leg(s)?

YESNO

9

Do you currently have or have you had a severe leg/foot infection such as gangrene (black skin tissue)?

YESNO

10

Have you been diagnosed with any of the following: diabetes, high blood pressure, or high cholesterol?

Diabetes

High cholesterol

Hypertension

None

11

Your Risk Factor Score

(0-4 Low Potential Risk), (5-9 Moderate Potential Risk), (10-14 High Potential Risk), (15+ Critical Potential Risk).

12

* This field is required.

Your Title

Your Last Name

Phone Number

How Did You Hear About Us?

Location