Peripheral Vascular Questionnaire

Please complete the following questionnaire and bring to your next appointment

Name: 

Date of Birth: 

Today's date: 

Do you experience aching, cramping or pain in your arms, legs, thighs or buttocks when you walk or exercise?

Yes    No

If you answered yes to question 1, does the pain subside with rest?

Yes    No

Do you have numbness and tingling in the arms or lower legs and feet?

Yes    No

Are your fingers or toes pale, discolored, or bluish?

Yes    No

Are your hands or feet cold to the touch?

Yes    No

Do you have any painful sores or ulcers on legs or fee that don't heal?

Yes    No

Do you now, or have you ever smoked cigarettes?

Yes    No

Do you have emphysema?

Yes    No

Do you have High blood pressure?

Yes    No   

Have you had any problems with your kidneys?

Yes    No

If yes, please describe:

Do you have High cholesterol?

Yes    No

Do you have Diabetes?

Yes    No

Do you exercise on a regular basis?

Yes    No

If not, what keeps you from exercising?

Are you more than 25 pounds overweight?

Yes    No

Do you have a family history of diabetes or cardiovascular problems? (immediate family such as parent, sister, brother)

Yes    No

Have you ever experienced a stroke, mini-stroke or percutaneous interventions on your peripheral circulation?

Yes    No

If yes, what surgery or intervention was performed?

When was that procedure performed?