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New Patient Information

Patient Information Sheet

Patient Name
Date*
 / 
 / 
DOB
 / 
 / 
Sex
Age*
Referring Physician
Reason for Visit

Please report any heart/circulation problems: Check all that apply

Please list any other heart conditions

Please check if you have had any of the following:

List any previous operations or other medical problems:

Circle all that apply

Current Smoker
Smoked in the Past
Alcohol Use
Illicit Drug Use

Family History of:

Heart Disease
High Blood Pressure
Stroke

Please check if you have any of the following:

Please check if you have any of the following:

Peripheral Arterial Disease (PAD) Questionnaire

Peripheral Arterial Disease (PAD) is a condition in which the arteries that carry blood to the muscles of the legs become narrowed and hardened due to the build up of plaque. It can result in leg pain or "fatigue," which can limit your physical activity. PAD can also increase your risk of having a heart attack or stroke if untreated.

Please take a moment to answer the questions below so that we may briefly screen you for PAD.

If you have any questions or concerns regarding PAD and your risk or would just like more information, please do not hesitate to ask.

1. Do you have any discomfort in the muscles of your legs when you walk that is relieved by rest?
2. Do your legs every feel fatigued or heavy when walking or active?
3. Do you ever need to stop and rest when walking of have difficulty keeping up with others?
4. Do your feet and toes bother you at night?
5. Would you have difficulty doing any of the following because of leg fatigue, weakness or discomfort?
Walking one block?
Climbing one flight of stairs?
Walking at an increased pace?

Venous Questionnaire

Diseases of leg veins, such as varicose veins (large bulging veins) or venous insufficiency (leaky leg veins) can cause pain, swelling, infections and ulcers. These can be frequently treated by ablation or laser treatment. Please check if you have any of the following symptoms.