• MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Peripheral Artery Disease (PAD) is a common circulation problem in which arteries carrying blood to the legs are not functioning well or become narrowed or clogged due to a build-up of plaque. Fill out this questionnaire so your physician can evaluate whether you may be at risk or have symptoms of PAD.

    Select YES or NO on the following questions and check all boxes that apply:

  • This field is for validation purposes and should be left unchanged.