Question 1 of 13

Do you experience any pain in your legs or feet while at rest?

• Yes
• No

Question 2 of 13

Do you have uncomfortable aching, fatigue, tingling, cramping orpain in your feet, calves, buttocks, hip or thigh during walking/exercise?

• Yes
• No

Question 3 of 13

If Yes to Question 2, does the pain go away when you stop walking/exercising?

• Yes
• No

Question 4 of 13

Do you feet get pale, discolored or bluish at any time during the day?

• Yes
• No

Question 5 of 13

Do you have an infection, skin wound or ulcer on your leg or foot that is slow to heal over the past 8-12 weeks?

• Yes
• No

Question 6 of 13

Do you have high cholesterol or other blood lipid (fat) problems or require cholesterol medication?

• Yes
• No

Question 7 of 13

Do you have high blood pressure or take medication to reduce blood pressure?

• Yes
• No

Question 8 of 13

Do you have diabetes?

• Yes
• No

Question 9 of 13

Do you have a history of chronic kidney disease?

• Yes
• No

Question 10 of 13

Do you currently or have you ever smoked?

• Yes
• No

Question 11 of 13

Do you have a history of stroke or mini-stroke (TIA)?

• Yes
• No

Question 12 of 13

Do you have a history of heart disease (heart attack, MI)?

• Yes
• No

Question 13 of 13

Do you have a history of carotid stenosis, AAA (abdominal aortic aneurysm), and/or stent placement?

• Yes
• No

Thank you for taking the P.A.D. questionnaire. To have your results review by a health care representative please submit the following information.

• First Name *
• Last Name *
• Email Address
• Phone *
• Risk Score *
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