Peripheral Arterial Disease Health Risk Assessment Form * Denotes required fields Please answer all the following questions and then click “Submit” to get your personal risk assessment. * Do you have high blood pressure? (Select one) Yes No * Do you smoke? (Select one) Yes No * Do you have high cholesterol? (Select one) Yes No * Do you consume an excessive amount of alcohol? (Select one) Yes No * Do you follow a poor diet? (Select one) Yes No * Do you have heart disease? (Select one) Yes No * Do you exercise less than 3 times per week, for 20 to 30 minutes at a time? (Select one) Yes No * Are you obese? (Select one) Yes No * Do you have a family history of peripheral arterial disease? (Select one) Yes No * Are you over the age of 65? (Select one) Yes No