Patient Questionnaire

Peripheral Arterial Disease Questionnaire

Answers to these questions will determine if you are at risk for PAD. Your answers to these questions can be used in discussions with your doctor about PAD.

"*" indicates required fields

1. Are you 65 years or older?*
2. Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when your walk, which is relieved by rest?*
3. If yes to #2, does this pain go away within 10-minutes after stopping?*
4. Do you experience any pain at rest in your lower leg(s) or feet?*
5. Are your toes or feet pale, discolored, or bluish?*
6. Do you have an infection, skin wound or ulcer on your feet or toes that are slow to heal (8-12 weeks)?*
7. Do you have high cholesterol or other blood lipid problems or take medication to lower your cholesterol level?*
8. Do you have high blood pressure or take medication for high blood pressure?*
9. Do you have diabetes?*
10. Do you have history of chronic kidney disease?*
11. Do you have a history of smoking?*
12. Have you had a stroke or mini-stroke (TIA)?*
13. Do you have coronary artery disease (blockage in the heart)?*

Learn more about how QuantaFlo may improve outcomes for your PAD patients

Learn More About QuantaFlo