Peripheral Arterial Disease

  1. 2. Race*
    BlackAsianHispanicWhiteOther
  2. 8. Are you Diabetic? *
    YesNo
  3. 9. Do you smoke?*
    YesNo
  4. 10. Have you been diagnosed with Coronary Artery Disease (CAD)?*
    YesNo
  5. 11. Have you been diagnosed with Cerebrovascular Disease (CVD)?*
    YesNo
  6. 12. Have you ever suffered from Congestive Heart Failure (CHF)?*
    YesNo
  7. 13. Do you get pain in the back of your legs when you walk that stops with rest?*
    YesNo
  8. 14. Have you been told you have vascular (arterial) disease in the legs?*
    YesNo

Book an appointment
Center is open from 8 AM - 5 PM on Mon - Fr
281-949-6020 office@coastalvascular.net
Same and next day appointments available!
Same and next day appointments available!