Vascular Health Assessment
Please complete the following assessment to help us understand your vascular health.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have a history of vascular disease?
*
Yes
No
Are you currently experiencing any of the following symptoms?
Do you smoke?
*
Yes
No
Former smoker
Do you have diabetes?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Please describe your physical activity level.
Please Select
Sedentary
Lightly active
Moderately active
Very active
Extra active
Additional comments or concerns
Submit
Should be Empty: