Georgia 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

We would like to thank you for taking the time to check your vascular health.

We will review your responses to see if you are at an elevated risk for PAD or another venous disease. If there are concerns, we will contact you.

We understand the critical importance of keeping your private information secure. Your information will never be shared with anyone.

Please contact our highly experienced team of vascular specialists if you have any concerns or questions about possible PAD symptoms. Our staff in Atlanta looks forward to hearing from you!

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

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