PAD and Abdominal Aortic Aneurysm (AAA) Risk Assessment Form

Please correct the errors described below.

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.

Risk Factors for PAD

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.


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.

Your information will be encrypted.