Endovascular Institute

Peripheral Artery Disease Screening

Peripheral Arterial Disease (P.A.D.) is a common circulation problem in which the blood vessels become narrowed or clogged. Please fill out this questionnaire to see if you have the symptoms of P.A.D.

Please type in your name, email address, and telephone number.

Click Yes or No: 

* Required fields
Name *
E-mail Address *
Telephone number: *
Do you experience aching, cramping or pain in your legs, thighs or buttocks when you walk or exercise? *	Yes No
If you answered yes, does the pain subside with rest? *	Yes No
Do you have numbness and tingling in the lower legs and feet? *	Yes No
Are your toes pale, discolored, or bluish? *	Yes No
Are your feet cold to the touch? *	Yes No
Do you have any sores or ulcers on legs or feet that don’t heal? *	Yes No
Do you have difficult to control blood pressure on more than 3 blood pressure medications? *	Yes No
Do you have a personal history of high blood pressure, diabetes, or aortic aneurysm? *	Yes No
Do you have a family history of high blood pressure, diabetes, or aortic aneurysm? *	Yes No
Have you ever experienced a stroke, mini-stroke or transient ischemic attack (TIA)? *	Yes No

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1190 NW 95 Street, Suite 101, North Miami, Florida 33150

Tel: 305.691.2941       Fax: 305.696.4435