PAD Risk Assessment Questionnaire
Please answer each of the questions below.

More information about Peripheral Arterial Disease (PAD):
https://bit.ly/PADSEng
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Your Name (First, Last) *
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. Do you have any of the following? *
Required
7. Have you been told you have vascular (arterial) disease in your legs? *
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