Vascular Health Assessment Form
Please complete this form to help us assess your vascular health risks and symptoms.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Contact Email
*
example@example.com
Do you have any of the following medical conditions? (Select all that apply)
*
High blood pressure (hypertension)
Diabetes
High cholesterol
Previous heart attack or stroke
Peripheral artery disease
None of the above
Other
Family history of vascular disease?
*
Yes
No
Not sure
Lifestyle Factors
*
Rows
Yes
No
Do you currently smoke?
1
2
Do you exercise regularly?
3
4
Do you consume alcohol?
5
6
Do you follow a healthy diet?
7
8
Please rate the severity of the following symptoms in your legs or arms over the past month:
*
Rows
None
Mild
Moderate
Severe
Pain or cramping during walking
9
10
11
12
Swelling
13
14
15
16
Numbness or tingling
17
18
19
20
Discoloration of skin
21
22
23
24
Ulcers or sores that do not heal
25
26
27
28
Are you currently taking any medications? Please list them below:
On a scale of 1 to 10, how would you rate your overall vascular health? (1 = Poor, 10 = Excellent)
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Signature (Please sign below to confirm the information provided is accurate)
*
Submit Assessment
Submit Assessment
Should be Empty: