myU OneStop



About the
EXERT Study



Peripheral
Artery Disease &
Claudication



Questionnaire


Brochure


Refer a Patient

In the News






Peripheral Artery Disease
and Claudication Questionnaire


 
Risk Factors


1) What is your age?

years

2) Do you smoke or have you ever smoked?
yes no

2a) For how long?

years

2b) How many packs per day

packs


3) Do you have diabetes?
yes no


4) Do you have or are you being treated for high blood pressure?
yes no


5) Do you have or are you being treated for high cholesterol?
yes no


6) Have you ever had angina, chest pain, a heart attack or stroke?
yes no




Symptoms


7) Do you have pain in your legs when you walk?
yes no


8) Where is this pain?


9) Do you get this leg pain when you walk at an ordinary pace on level ground?
yes no


10) How far can you walk without stopping?

11) Does this leg pain change when you walk uphill or hurry?
yes no

12) Does this pain go away when you rest?
yes no


13) What happens to this leg pain when you stand still?


14) Does this pain ever begin when you are standing or sitting?
yes no


15) Does this pain ever disappear while you are walking?
yes no




Contact Information

First Name

Last Name
Street Address
City
State
ZIP
Email Address
Phone Number