PAD Survey

Pad-Survey

Patient Questionnaire for Symptoms Suggestive of Autonomic Dysfunction:

Patient Name:

Patient Name:(Required)

Last Name(Required)

Do you have diabetes?(Required)

Yes

Have you had low blood sugar (with our without fainting) and not been aware of it?*(Required)

Yes

Do you sweat when you cat, even if the food is not spicy, or do you have dry skin on your hands or feet?(Required)

Yes

Do you have _______ in your feet? Check which symptom(s) you have(Required)

Do the bedsheets or your socks bother or hurt your feet?(Required)

Yes

Do you have _______ in your feet? Check which symptom(s) you have(Required)

Do you have trouble driving or seeing at night?(Required)

Yes

Do you feel dizzy or faint when you stand up too quickly?(Required)

Yes

Do you feel bloated or full after the first few bites of food?(Required)

Yes

Do you get tired as soon as you start to exercise?(Required)

Yes

Do you have diarrhea at night?(Required)

Yes

Do you have urinary incontinence?(Required)

Yes

Men only: do you have difficulty with erections that has not improved with medications like Viagra or Cialis?(Required)

Yes

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 Name(Required)

Last Name(Required)

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

Yes

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

Yes

Do your feet get pale, discolored or bluish at any time during the day?(Required)

Yes

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?(Required)

Yes

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

Yes

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

Yes

Do you have diabetes?(Required)

Yes

Do you have a history of chronic kidney disease?(Required)

Yes

Do you currently or have you ever smoked?(Required)

Yes

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

Yes

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

Yes

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

Yes

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PAD Survey

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