Full Name *

Phone *

Email *

Postal code

History

Please check all that apply

I have diabetes.

I have heart disease.

I have high blood pressure.

I have kidney disease.

I currently smoke or previously smoked.

I have high cholesterol.

I have a family history of PAD.

I am over 50 years old.

Symptoms

Do you have muscle cramping in the thighs, legs or hips?

Yes

No

Do you have color changes to legs, feet and toes (paleness or blueness)?

Yes

No

Have you experienced leg pain at rest: prolonged aching in the muscles that does not subside, even at rest?

Yes

No

Do you have cold feet and/or legs?

Yes

No

Do you have leg or foot wounds that are slow to heal or do not heal at all?

Yes

No

Questions/Comments

I agree to the Terms and Conditions. *

Yes

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