Find a Location
+1 (904) 384-3343
Home
Team
JVC
Conditions Treated
FAQs
Contact
Blog
Patient
Portal
Online
Bill Pay
Home
Team
JVC
Conditions Treated
FAQs
Contact
Blog
Find a Location
Home
Team
JVC
Conditions Treated
FAQs
Contact
Blog
Type To Search
Home
Team
JVC
Conditions Treated
FAQs
Contact
Blog
Patient Portal
Make a Payment
Peripheral Arterial Disease Screening Questionnaire
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Date of Birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
Account #
(Required)
We want to make you aware of a condition that may affect you. Peripheral Arterial disease (PAD) affects millions of Americans every year. It is a condition in which the arteries that carry blood to the muscles of the legs become narrowed due to the buildup of plaque. This is the same disease process that causes blockages in the heart. Having PAD may also increase your risk of heart attack, stroke, and limb amputation if untreated. Please take a moment to answer the questions below so that we may briefly screen you for PAD. If you have any questions or concerns regarding PAD and your risk, please do not hesitate to ask.
Are you 50 years old or older?
(Required)
Select
Yes
No
Do you smoke?
(Required)
Select
Yes
No
Have you ever smoked?
(Required)
Select
Yes
No
Have you ever been diagnosed with any of the following?
Diabetes
Chronic kidney disease
High blood pressure
High cholesterol
Do you have a family history of PAD?
(Required)
Select
Yes
No
Have you ever been diagnosed with PAD, cardiac disease, heart attack or stroke?
(Required)
Select
Yes
No
Have you ever had a procedure to improve the blood flow to your heart or legs?
(Required)
Select
Yes
No
Do you have leg muscle (buttock, thigh or calf) pain when walking that goes away with rest?
(Required)
Select
Yes
No
When you inspect your toes and feet, do they look pale, discolored, or bluish?
(Required)
Select
Yes
No
If you have leg pain, does it disturb your sleep?
(Required)
Select
Yes
No
Have you experienced sores or wounds on the toes, feet or legs that heal slowly or not at all?
(Required)
Select
Yes
No
Have you noticed poor nail growth and decreased hair growth over time on the toes and legs?
(Required)
Select
Yes
No
Comments
This field is for validation purposes and should be left unchanged.
#thegov_button_6733759f2c731 { color: rgba(255,255,255,1); }#thegov_button_6733759f2c731:hover { color: rgba(49,49,49, 1); }#thegov_button_6733759f2c731 { border-color: rgba(49,49,49,0); background-color: rgba(239,62,66,1); }#thegov_button_6733759f2c731:hover { border-color: rgba(239,62,66,1); background-color: rgba(255,255,255,1); }
Skip to content
Open toolbar
Accessibility Tools
Accessibility Tools
Increase Text
Increase Text
Decrease Text
Decrease Text
Grayscale
Grayscale
High Contrast
High Contrast
Negative Contrast
Negative Contrast
Light Background
Light Background
Links Underline
Links Underline
Readable Font
Readable Font
Reset
Reset