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PAD Risk Assessment Questionnaire
Please answer each of the questions below.
More information about Peripheral Arterial Disease (PAD):
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* Required
Your Name (First, Last)
*
Your answer
Phone Number
*
Your answer
Email Address
Your answer
1. Gender
*
Female
Male
2. Race
*
Asian
Black
Hispanic
White
Other
3. Date of Birth
*
MM
/
DD
/
YYYY
4. Height in Feet and Inches (example: 5'4")
*
Choose
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
7'7"
7'8"
7'9"
7'10"
7'11"
5. Weight (Pounds)
*
Your answer
6. Do you have any of the following?
*
Diabetes
Coronary Artery Disease (CAD) or Heart Attack
Cerebrovascular Disease (CVD) or Stroke
Congestive Heart Failure (CHF)
High Cholesterol
Hypertension or High Blood Pressure
Kidney Disease
History of Smoking (Past or Current)
Leg Pain after walking
Non-healing wounds on your Legs or Feet
None of the Above
Required
7. Have you been told you have vascular (arterial) disease in your legs?
*
Yes
No
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