PAD Questionnaire
The purpose of this test is to help us determine if you are at risk for Peripheral Arterial Disease (PAD) and whether or not you have symptoms of Chronic Venous Insufficiency (CVI). The test includes 2 sections regarding the two conditions.

Firstly, please fill in your basic personal information before doing the test.

First Name *
Last Name *
Date of Birth *
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Phone Number *
Email Address *
Are you at risk for Peripheral Arterial Disease?
Peripheral Arterial Disease (PAD) is a common circulation problem in which blood vessels that carry blood to the legs or arms become narrowed or clogged.

Please answer these questions to identify if you have symptoms of PAD.

1. When you walk or exercise, do you experience aching, cramping or pain in your arms, legs, thighs or buttocks? *
2. Do you have any painful sores or ulcers on your legs or feet that are not healing? *
3. Have you had surgery, balloon procedures, or stents placed to any blood vessels other than your heart? *
4. Do you have High Cholesterol? *
5. Do you have a History of Smoking? *
6. Do you have High Blood Pressure? *
7. Are you Diabetic? *
8. Have you had any decrease in sexual function - (Erectile Dysfunction)? *
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