PAD and Abdominal Aortic Aneurysm (AAA) Risk Assessment Form

Peripheral Arterial Disease is a common and often silent condition that affects the circulation To the legs and feet, initially causing aching, pain, cramping and fatigue. The arteries become Narrowed and walking may become more difficult or painful. This condition can lead to foot and leg wounds or ulcers that don’t heal or are very slow to heal, and potentially lead to amputations if left untreated.

The below assessment will help to identify your risk for Peripheral Arterial Disease. Please complete both sections in their entirety.

Patient's Name

Date

Street Address

City

State

Zip Code

Email address

Birthdate

Current Age

Risk Factors for PAD

1. Do you have leg pain with exertion? (e.g. while walking)

Yes No

2. Are you a current or former smoker

Yes No

3. Do you have Diabetes?

Yes No

4. Are you on dialysis?

Yes No

5. Have you had any lower leg, ankle or foot wounds that are /were slow to heal?

Yes No

6. Have you ever had a vascular bypass in the leg(s)?

Yes No

7. Have you ever had a toe or partial foot/leg amputation?

Yes No

You have answered yes to one of these questions. A member of our clinic team will reach out to you within two business days to discuss further action." at the bottom of the form. For the Spanish form, please just using Google translate. Thanks.

IMPORTANT INFORMATION:

On the reverse, please see Clinical Guidelines for Peripheral Arterial Disease and Considerations for Next Steps.

Clinical Guidelines for Peripheral Arterial Disease

Critical characteristics of patients at risk for the peripheral arterial disease are defined as individuals with one or more of the following

Patients over 65 years old.
Patients 50 years or older and a history of smoking or diabetes.
Leg symptoms with exertion (claudication.)
Non-healing wounds (lower extremity)

Non-invasive diagnostic testing is the initial step in establishing the presence and extent of lower extremity PAD in patients identified to be at risk for the disease.

Vascular diagnostic laboratories could use segmental pressures, Doppler waveform analysis, pulse volume recordings, or ABI with duplex ultrasonography (or some combination of these methods) to document the presence and location of PAD in lower extremity.

Considerations for Next Step

Non-invasive testing should be considered for patients with a positive finding on the PAD risk assessment

65 years or older
50 years or older and answered “yes” to questions 1 or 2 of the Risk Factors for PAD
Answered “yes” to questions 3 or 4 of the Risk Factors for PAD
A onetime aortic duplex ultrasound is recommended in all male patients between 65 and 75 who have smoked more than 100 cigarettes in their life.

An annual risk assessment is suggested for all dialysis patients, as they have a high prevalence of peripheral arterial disease.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Email address

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