Pad Survey elitefaor - Pad-Survey and Neuropathy Questionnaire Pad-Survey Patient Questionnaire for Symptoms Suggestive of Autonomic Dysfunction: Patient Name:* First NameLast Name Do you have diabetes?* YesNo Have you had low blood sugar (with our without fainting) and not been aware of it?* YesNo Do you sweat when you cat, even if the food is not spicy, or do you have dry skin on your hands or feet?* YesNo Do you have _______ in your feet? Check which symptom(s) you have* PainTinglingBurningNumbnessElectrical ShocksNone of the above Do the bedsheets or your socks bother or hurt your feet?* YesNo Do you have _______ in your hand? Check which symptom(s) you have* PainTinglingBurningNumbnessElectrical ShocksNone of the above Do you have trouble driving or seeing at night?* YesNo Do you feel dizzy or faint when you stand up too quickly?* YesNo Do you feel bloated or full after the first few bites of food?* YesNo Do you get tired as soon as you start to exercise?* YesNo Do you have diarrhea at night?* YesNo Do you have urinary incontinence?* YesNo Men only: do you have difficulty with erections that has not improved with medications like Viagra or Cialis?* YesNo American Heart Association Pad-Survey Answers to the following questions will help determine if you are at risk for Peripheral Arterial Disease (PAD) and if a vascular examination can help better assess your voscular health status. Patient Name* First NameLast Name Do you experience any pain in your legs or feet while at rest?* YesNo Do you have uncomfortable aching, fatigue, tingling, cramping or pain in your feet, calves, buttocks, hip or thigh during walking/exercise?* YesNo Does the pain go away when you stop walking/ exercising?* YesNo Do your feet get pale, discolored or bluish at any time during the day?* YesNo 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?* YesNo Do you have high cholesterol or other blood lipid (fat) problems or require cholesterol medication?* YesNo Do you have high blood pressure or take medication to reduce blood pressure?* YesNo Do you have diabetes?* YesNo Do you have a history of chronic kidney disease?* YesNo Do you currently or have you ever smoked?* YesNo Do you have a history of stroke or mini-stroke (TIA)?* YesNo Do you have a history of heart disease (heart attack, MI)?* YesNo Do you have a history of carotid stenosis, AA (abdominal aortic aneurysm), and/ or stent placement?* YesNo Next Neuropathy-Questionnaire Patient Questionnaire for Symptoms suggestive of Autonomic Dysfunction: Name* First NameLast Name 1. Do you have diabetes?* YesNo 2. Have you had low blood sugar (with our without fainting) and not been aware of it?* YesNo 3. Do you sweat when you eat, even if the food is not spicy, or do you have dry skin on your hands or feet?* YesNo 4. Do you have pain, tingling, burning, numbness, or electrical shocks in your feet. ?* YesNo 5. Do the bedsheats or your socks bother or hurt your feet ?* YesNo 6. Do you have pain, tingling. burning, numbness, or electrical shocks in your hands ?* YesNo 7. Do you have trouble driving or seeing at nigh ?* YesNo 8. Do you feel dizzy or faint when you stand up too quickly?* YesNo 9. Do you feel bloated or full after the first few bites of food'?* YesNo 10. Do you get tired as soon as you start to exercise ?* YesNo 11. Do you have diarrhea at night?* YesNo 12. Do you have urinary incontinence?* YesNo 13. Men only: do you have difficulty with erections that has not improved with medications like Viagra or Cialis? YesNo BackSubmit Should be Empty: