PAD Questionnaire
Please answer each of the questions below.

More information about Peripheral Arterial Disease (PAD):

First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
1. Gender *
2. Race *
3. Date of Birth *
4. Height in Feet and Inches (example: 5'4") *
5. Weight (Pounds) *
Your answer
6. Systolic Blood Pressure *
top number
Your answer
7. Diastolic Blood Pressure *
bottom number
Your answer
8. Are you Diabetic? *
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)? *
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? *
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