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Survey Maker

Peripheral Vascular Disease Assessment

The St. Anthony's Hospital Vascular Center invites you complete and submit this free peripheral vascular disease risk assessment. This assessment is not intended to replace and diagnosis and/or recommendations by your personal physician. St. Anthony's Health Care team will contact you regarding the results.

* Indicates required information

Please provide the following information to help us best serve you.

First Name *
Last Name *
Email *
Street *
City *
State *
Zip *
Phone
Year of Birth (yyyy) *
Gender *

1. *
Do you have cardiovascular problems, such as heart attack or angina?
 
 
2. *
Do you suffer from high blood pressure?
 
 
3. *
Is your blood pressure difficult to control with medications?
 
 
4. *
Have you ever had a stroke?
 
 
5. *
Do you have diabetes?
 
 
6. *
Do you have a family history of diabetes? (e.g. parents or siblings)
 
 
7. *
Do you have a family history of cardiovascular problems?
 
 
8. *
Do you have aching, cramping or leg muscle pain when you walk or exercise that goes away after rest?
 
 
9. *
Do you have any ulcers or sores on your feet or legs that are slow in healing?
 
 
10. *
Do you have pain in the balls of your feet?
 
 
11. *
Do you smoke?
 
 
12. *
Have you ever smoked?
 
 
13. *
Are you more than 25 pounds overweight?
 
 
14. *
Do you eat fried or fatty food three times a week or more?
 
 
15. *
Do you have an inactive lifestyle?
 
 

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