Peripheral Arterial Disease Questionnaire

Do I Need to Test for PAD

Peripheral arterial disease (PAD) is a serious circulatory problem in which the blood vessels that carry blood to your arms, legs, brain, or kidneys become narrow or clogged. It affects over 8 million Americans, most over the age of 50. It may result in leg discomfort when walking, poor healing of leg sores and ulcers, difficulty to control blood pressure or symptoms of a stroke. People with PAD are at a significantly increased risk for stroke and heart attack. Answers to these questions will determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.

Name

Date

1. When walking, do you have foot, calf, buttock, hip, or thigh discomfort (aching, fatigue, tingling, cramping, or pain) which is relieved by rest? (440.21)

Yes No

2. Do you experience any pain in your lower legs or feet when at rest? (440.22)

Yes No

3. Do you experience foot or toe pain that often disturbs your sleep? (440.22)

Yes No

4. Are your toes or feet pale, discolored, or bluish? (444.22)

Yes No

5. Do you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks?) (440.23)

Yes No

6. Has your doctor ever told you that you have diminished or absent pedal (foot) pulses? (443.9)

Yes No

7. Have you suffered a severe injury to your legs or feet? (904.8)

Yes No

8. Do you have an infection of the legs or feet that may be gangrenous (black skin tissue)? (440.24)

Yes No

Patient’s Signature

If you checked yes for any of the above questions, you may have vascular disease.

What is peripheral arterial disease?
Your arteries distribute oxygen-rich blood from your heart to other parts of your body. Your peripheral arteries carry blood away from the heart to your arms and legs. The peripheral arteries in your legs are extensions of the largest artery in your body, the aorta. The aorta travels down through your abdominal region and branches off into the iliac arteries of both legs. The iliac arteries divide into smaller arteries and carry blood down your legs and to your toes.

Healthy peripheral arteries are smooth and unobstructed, allowing blood to flow freely to the legs and supply oxygen, glucose, and other necessary nutrients. Typically with age, the peripheral arteries collect plaque, a sticky substance made up of fat and cholesterol. Plaque narrows the passageway within the arteries and causes them to become rigid. Peripheral arterial disease results when the peripheral arteries become too narrow or blocked and limit blood flow to the legs. If left untreated, the peripheral arterial disease can cause pain or ache in the legs, difficulty with walking, resting pain in the feet at night in bed, and non-healing sores or infections in the toes or feet. In its most severe form, it can lead to limb loss. In addition, it can be associated with other serious arterial conditions that can lead to heart attacks and stroke.

Peripheral arterial disease can be diagnosed, along with its severity, by a simple, non-invasiveDoppler examination.

Vascular surgeons are the only physicians treating vascular disease today who can provide all the treatment options available.

Causes and risk factors:

Age
Diabetes
Family history of vascular problems
Gender—males are more prone to the condition than females
High cholesterol
Hypertension
Lack of exercise
Obesity
Smoking

Peripheral arterial disease can be treated with lifestyle changes, medications, minimally invasive angioplasty/stenting, or open bypass surgery. The treatment depends upon the severity of the condition.

New Orleans Podiatry Associates

2626 Jena Street, New Orleans, LA 70115 - t. 504.897.3627 f. 504.897.3339
3939 Houma Blvd, Bldg. 5, Ste. 217, Metairie, LA 70006 - t. 504.457.2300 f. 504.897.3339nolapodiatry.com | nolapodiatry@gmail.com

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