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   The Doctors
  Dr.Richard Berliner
  Dr.Jill Berkowitz - Berliner









Do I need a test for PAD?

Peripheral Arterial Disease (PAD) is a serious circutcarry latory problem in which the blood vessels that carry blood to your arms, legs, brain, or kidneys, become narrowed or clogged. it affects over 8 million Americans, most over the age of 50. It may resuly in leg discomfort with walking poor healing of leg sores/ulcers, difficult to control blood pressure, or symptoms of stroke. People with PAD are at significantly increased risk for stroke and heart attack. Answers to these questions will be determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.


Name : ________________________________

Date : _____________________

Cirlce "Yes" or "No" :     Test for PAD
1 Do you have foot, calf, buttock, hip or thigh discomfort (aching, farigue, tingling, cramping or pain) when you walk which is relieved by rest ? Yes No
2 Do you experience any pain at rest in your lower leg(s) or feet? Yes No
3 Do you experience foot or toe pain that often disturb your sleep ? Yes No
4 Are your toes or feet pale, discolored, or bluish ? Yes No
5 Do you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks)? Yes No
6 Has your doctor ever told you that you have diminished or absent pedal (foot) pulses? Yes No
7 Have you suffered a severe injury to the leg(s) or feet ? Yes No
8 Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)? Yes No

Patient Signature : __________________________________

Date : ____________________

Physician Signature : __________________________________

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