Texas Endovascular - PAD Risk Assessment

Check Your Risk for Peripheral Artery Disease (PAD)

Risk factors that increase the chance you may develop PAD.

Are you 50 years old or older?*

YesNo

Do you smoke or did you smoke?*

YesNo

Have you been diagnosed with any of the following:

Diabetes?*

YesNo

Chronic kidney disease?*

YesNo

High blood pressure?*

YesNo

High cholesterol*

YesNo

Symptoms that may be signs you have PAD. Do you...

Experience tiredness, heaviness, or cramping in the leg muscles?*

YesNo

Have toes or feet that look pale, discolored or blue?*

YesNo

Experience leg or foot pain that disturbs your sleep?*

YesNo

Have sores or wounds on your toes, feet, or legs that heal slowly or not at all?*

YesNo

Have a leg or foot that feels colder than the other?*

YesNo

Have thick, yellow toenails that aren’t growing?*

YesNo

Contact Information

Thanks for taking our quiz! If your responses indicate that you might have symptoms of PAD or another vascular concern, we will be in touch.

Your privacy is very important to us. We will not sell or share your information outside of our practice.

If you have questions or concerns about your vascular health, including any symptoms you might be experiencing, we would be happy to hear from you! Feel free to give us a call.

First Name **

Last Name **

Phone Number **

Email **

Preferred Location **

Date of Birth **

How did you hear about us? * *

LIINE LOCATION

Have you scheduled an appointment with us before? **

LIINE IS NEW

Phone Condition

Total Score

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