PAD Questionnaire

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 narrowed or clogged. It affects over 8 million Americans, most over the age of 50. It may result in leg discomfort with walking, poor healing of leg sores/ulcers, difficult to control blood pressure, or symptoms of stroke. People with PAD are at 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.

Select “Yes” or “No”:

1. Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest?

Yes No

2. Do you experience any pain at rest in your lower leg(s) or feet?

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

7. Have you suffered a severe injury to the leg(s) or feet?

Yes No

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

Yes No

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

Electronic signature

Date

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Physician signature

Date

Test for PAD

Yes No

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