Vascular Screening Risk Assessment
Vascular disease occurs when there is an interruption to normal blood flow within your body’s circulatory system. A lack of blood flow and oxygen to your brain, heart or lungs can be life threatening. Therefore, it is important to understand your risk for this serious disease. Please complete the screening below to help us determine your level of risk and help you to take control of your vascular health.
MaleFemale	Age:	Zip Code:

Do you smoke cigarettes or other tobacco products?		YesNo
Do you have diabetes?		YesNo
Are you taking medication to control your blood pressure?		YesNo
Are you taking medication to control your cholesterol?		YesNo
Do you have sores on your leg(s) that are slow to heal or do not heal?		YesNo
Do you experience leg cramping while walking?		YesNo
Have your parents, brother(s) or sister(s) had any of the following conditions before the age of 55?
Stroke		YesNoUnknown
High Blood Pressure		YesNoUnknown
Diabetes		YesNoUnknown
Heart Disease		YesNoUnknown
Have you been diagnosed with any of the following?
Transient Ischemic Attack (TIA)		YesNo
Blockage within your carotid artery		YesNo
Blockage within your legs		YesNo
Aneurysm		YesNo

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