TODAY'S DATE* MM slash DD slash YYYY NAME* First Last DATE OF BIRTH* 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:1. Have you ever been diagnosed with Peripheral Vascular Disease or been diagnosed as having poor circulation? Yes No 2. Have you ever had surgery, balloon procedures or stents in your heart, kidneys, belly, legs, or arms? Yes No If yes, dates: 3. When you walk, do you experience aching, cramping or pain in your legs, thighs, or buttocks? Yes No 4. If you answered Yes to #3, when do you feel the pain: After walking 1 block Climbing a flight of stairs After walking 100 yards Walking at increased speed 5. If you answered Yes to #3, check the area(s) of the body below where you feel pain. Head Chest Left Arm Right Arm Left Hand Right Hand Abdomen Left Leg Right Leg Left Knee Right Knee Left Foot Right Foot 6. If you have pain, does the pain subside with rest? Yes No 7. Do your feet or toes bother you most nights while lying in bed, with relief when they are dangled at the edge of the bed? Yes No 8. Do you have any painful sores or ulcers on legs or feet that do not heal? Yes No 9. Are your legs discolored or bluish? Yes No 10. Check all that apply: I am a current smoker I have a history of smoking I have diabetes I have a family history of diabetes I have high cholesterol I have a family history of high cholesterol I have high blood pressure/hypertension I have a family history of high blood pressure/ hypertension I have/had coronary artery disease (CAD)/heart attack I have a family history of coronary artery disease (CAD) /heart attack I have had a stroke/mini-stroke/TlA I have a family history of stroke/mini-stroke/TlA CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.