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
Your answer
Last Name
Your answer
Phone Number
Your answer
Email Address
Your answer
1. Gender
2. Race
3. Date of Birth
MM
/
DD
/
YYYY
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)?
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?
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