Peripheral Artery Disease (PAD) Risk Quiz

1

Age* This field is required.

2

Gender* This field is required.

Male

Female

Other / Prefer not to say

3

Do you currently smoke or have you smoked in the past?* This field is required.

Yes, currently smoke

Yes, smoked in the past

No, never smoked

4

Have you been diagnosed with diabetes?* This field is required.

Yes

No

5

Do you have high blood pressure (hypertension)?* This field is required.

Yes

No

Not sure

6

Do you have high cholesterol?* This field is required.

Yes

No

Not sure

7

Have you experienced pain, aching, or cramping in your legs when walking or exercising that improves with rest?* This field is required.

Yes

No

8

Do you have wounds or sores on your feet or legs that are slow to heal?* This field is required.

Yes

No

9

Do you have a family history of Peripheral Artery Disease, heart disease, or stroke?* This field is required.

Yes

No

Not sure

10

Full Name* This field is required.

First Name

Last Name

11

Contact Information* This field is required.

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