Free PAD Screening - Ashchi Heart & Vascular Center

First Name*

Last Name*

City*

State*

Email Address*

Phone Number*

Desired Appointment Time*

Are your feet cold to the touch?*

Do you experience aching, cramping or pain in your legs, thighs or buttocks when you walk or exercise?*

Do you have any sores or ulcers on your legs or feet that don’t heal? *

If you do experience pain or discomfort in your legs, does the pain subside with rest?*

Do you have numbness and tingling in the lower legs and feet?*

Do you have difficulty controlling your blood pressure on more than 3 blood pressure medications?*

Are your toes pale, discolored or bluish?*

Do you have a personal history of high blood pressure, diabetes or aortic aneurysm?*

Do you have a family history of high blood pressure, diabetes or aortic aneurysm?*

Have you ever experienced a stroke, mini-stroke or transient ischemic attack (TIA)? *

Do you or have you had an ulcer on your legs or feet? *

Have you had a procedure on your arteries before (stents, balloons, angioplasty)*