Name_________________                

                                                                 

Do I Need a Test For PAD?

Peripheral Arterial Disease (PAD) is a serious circulatory problem in which the blood vessels that carry blood to your arms, legs, brain and kidneys, become narrowed or clogged.  It affects over 8 million Americans, most over the age of 50. It may result in leg discomfort with walking, poor healing of leg sores/ulcers, difficult to control blood pressure, or symptoms of stroke. People with PAD are at significantly higher risk of stroke and heart attack. Answers to these questions will help determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.

                                                                                  Answer Yes or NO 

1.

Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest? (I70219)

 

 

 

 

2.

Do you have a history of cardiovascular disease or diabetes and experience any pain or swelling at rest in your lower legs or feet? (I70229)

 

 

 

 

3.

Do you have a history of cardiovascular disease or diabetes and experience any leg, foot, or toe pain that often disturbs your sleep? (I70229)

 

 

 

 

 

 

 

 

4.

Do you have an ulcer on your thigh, calf, ankle, foot or toe that is slow to heal? (I7025)

 

 

 

 

5.

Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)? (I70269)

 

 

 

 

6.

Has a physician ever diagnosed you with Raynaud’s Syndrome? (R209)

 

 

 

 

 

Please Circle All That Apply:

 

 

 

 

 

 

Hair Loss on Legs                        Coolness/ Bluish Color on Feet                     Diabetes  

 

Hypertension                                Lack of Toe Nail Growth                 Over the Age of 70  

 

Current or Past Smoker                Shiny Thin Skin on Legs                  Circulatory Issues

 

 

           

 

Other comments or Notes:                              ____________                   Vascular Consult   □

Date:  ________________