PAD SCREENING

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 the 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