Contact Us Technical Assistance Peripheral Arterial Disease (PAD) Patient Questionnaire Form Home » Services » Interventional Radiology » Peripheral Arterial Disease (PAD) » Patient Questionnaire Form SymptomsDo you have pain or cramping in the muscle of your buttock, thigh, or calf when you walk? If so where? (NOT knee, hip or back pain)*YesNoLocation of pain or cramping*Does pain stop when you stop walking?*YesNoIf so, how far can you walk before the pain goes away?10ft = walking in the house100 ft = walking from parking lot to store entrance100 yards = walking 1 block or parking lot to doctors office200 yards = walking 2 blocksDo you have pain at rest?*YesNoDo you have pain all the time?*YesNoDo you have pain in the muscle of your buttock, thigh, or calf when you climb stairs?*YesNoDo you wake up at night due to burning and tingling in your feet that is relieved by dangling your feet over the bed or having to stand up?*YesNoDo you or have you had a wound or sore on your feet that is slow to heal?*YesNoIf yes to any of the above, you should be screened for peripheral arterial disease (PAD).Do you have leg swelling or varicose veins?*YesNoIf Yes, you may also suffer from venous insufficiency and should have a venous evaluation too.HistoryHave you had stents placed in your legs or heart previously? Or previous bypass surgery in the legs or heart in the past?*YesNoHave you been diagnosed with coronary artery disease, carotid artery disease (arteries in the neck), kidney artery disease? Had a previous heart attack?*YesNoHave you ever been told you have poor pulses in your feet?*YesNoIf yes to any of the above, you should be screened for Peripheral Arterial Disease.Risk FactorWhat is your age?*Age greater than 70 yrs old is by itself a risk factor for PAD.If you are 70 yrs old or older you should be screened for peripheral arterial disease (PAD).Do you have any of the following risk factors:Current or previous smoker?*YesNoDiabetes?*YesNoHigh cholesterol?*YesNoHypertension?*YesNoIf you are older than 50 years of age and have any of these risk factors for PAD, or you are younger than 50 years and have diabetes with 1 additional risk factor above, you should be tested for PAD.Submit your scores to Austin Radiological Association* Yes, I consent to submit my scores Name* First Last Email* Phone*Prefer:*EmailPhoneEmailThis field is for validation purposes and should be left unchanged.