Peripheral Vascular Disease Evaluation Form
Please complete this form to assist in the evaluation of peripheral vascular disease symptoms, risk factors, and relevant medical history.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Symptoms (check all that apply)
*
Leg pain with walking (claudication)
Rest pain in legs or feet
Non-healing wounds or ulcers
Numbness or tingling
Color changes in legs/feet
No current symptoms
Other
Relevant Medical History and Risk Factors (check all that apply)
*
Diabetes
High blood pressure (hypertension)
High cholesterol
History of heart disease
Smoking (current or former)
Family history of vascular disease
None of the above
Other
Have you had any prior vascular testing or treatment?
*
No
Yes, non-invasive testing (e.g., ultrasound, ABI)
Yes, invasive testing (e.g., angiogram)
Yes, prior vascular surgery or procedure
Current Medications (please list all)
*
Red-flag symptoms (check any that apply)
*
Sudden severe leg pain
Cold or pale limb
Numbness or weakness unable to move limb
Rapidly worsening wounds
None of the above
On a scale of 1 to 10, how severe are your leg symptoms at their worst?
*
No symptoms
1
2
3
4
5
6
7
8
9
Worst possible
10
1 is No symptoms, 10 is Worst possible
Please provide any additional information relevant to your vascular health or concerns.
Submit Evaluation
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