PAD Questionnaire
Please answer each of the questions below.

More information about Peripheral Arterial Disease (PAD):
http://www.radiologyinfo.org/en/info.cfm?pg=pad

First Name *
Last Name *
Phone Number *
Email Address *
1. Gender *
2. Race *
3. Date of Birth *
MM
/
DD
/
YYYY
4. Height in Feet and Inches (example: 5'4") *
5. Weight (Pounds) *
6. Systolic Blood Pressure *
top number
7. Diastolic Blood Pressure *
bottom number
8. Are you Diabetic?
Clear selection
9. Do you smoke? *
10. Have you been diagnosed with Coronary Artery Disease (CAD)? *
Heart disease
11. Have you been diagnosed with Cerebrovascular Disease (CVD)? *
Stroke
12. Have you ever suffered from Congestive Heart Failure (CHF)? *
13. Do you get pain in the back of your legs when you walk that stops with rest? *
14. Have you been told you have vascular (arterial) disease in the legs? *
15. Do you have Health Insurance? *
16. Would you like to be contacted by NIRP if you are found to be at risk for PAD? *
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