PAD Risk Assessment Questionnaire
This short questionnaire will help us determine if you are likely to have, or at risk of developing, Peripheral Arterial Disease (PAD). Please answer each of the questions below. 



If you want to learn more about PAD, click here: 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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