WHAT IS YOUR CIRCULATION ASSESSMENT™ ?

Your Circulation Assessment is a combination of more than one sign or symptom. Please answer all questions, select "YES" for all pertinent positives.

1.
Do you have Diabetes?
 YES NO 
2.
Do you have Heart Disease?
 YES NO 
3.
Do you smoke?
 YES NO 
4.
Have you ever smoked?
 YES NO 
5.
Do you have an inactive lifestyle or work environment?
 YES NO 
6.
Do you have high blood pressure?
 YES NO 
7.
Are you on 2 or more blood pressure medications?
 YES NO 
8.
Do you have high cholesterol?
 YES NO 
9.
Do you have COPD?
 YES NO 
10.
Have you had any problems with your kidneys?
 YES NO 
11.
If you don't exercise on a regular basis, please answer YES.
 YES NO 
12.
Are you 25 pounds overweight?
 YES NO 
13.
Are you over age 50 and a smoker or diabetic?
 YES NO 
14.
Are you over age 60?
 YES NO 
15.
Are you over age 70?
 YES NO 
16.
Do you snore?
 YES NO 
17.
Do you have a family history of diabetes?
 YES NO 
18.
Do you have a family history of cardiovascular disease?
 YES NO 
19.
Do you eat fried or fatty foods 3 or more times per week?
 YES NO 
20.
Have you ever had any procedures to clean out clogged/blocked arteries?
 YES NO 
21.
Do you have numbness and tingling in the arms, lower legs or feet? NCV's (hypoxia vs DM)
 YES NO 
22.
Any changes in your vision such as one eye going dark for a period of time?
 YES NO 
23.
Have you noticed or been told that your speech was garbled or slurred?
 YES NO 
24.
Have you noticed or been told that your lip was drooping?
 YES NO 
25.
Have you noticed any changes in hand or leg strength, feeling or coordination?
 YES NO 
26.
Arm or hand pain with activity such as combing your hair?
 YES NO 
27.
Recurrent lightheadedness, or near fainting with head motion or the use of your arm?
 YES NO 
28.
Have you been told one arm is better for taking your blood pressure than the other?
 YES NO 
29.
Have you ever experienced a Stroke (CVA - Cerebrovascular Accident)?
 YES NO 
30.
Have you ever experienced a TIA (Transient Ischemic Attack)?
 YES NO 
31.
Have you ever experienced temporary weakness of an arm on one side of the body?
 YES NO 
32.
Have you ever had an indwelling catheter (PICC or port) for treatment of infection or cancer?
 YES NO 
33.
Have you ever had a DVT in your upper extremities?
 YES NO 
34.
Do you have swelling in your arms or hands?
 YES NO 
35.
Do you have aching pain or heaviness in the arm?
 YES NO 
36.
Do you notice bluish discoloration of the arm?
 YES NO 
37.
Do you have cold or painful hands or fingers?
 YES NO 
38.
Do you have non-healing ulcers of the upper extremities?
 YES NO 
39.
Are your hands cold to the touch?
 YES NO 
40.
Have you lost weight in the past 3 months?
 YES NO 
41.
Has your appetite changed?
 YES NO 
42.
Do you have pain in your abdomen after eating?
 YES NO 
43.
Do you experience a thumping sensations in the abdomen?
 YES NO 
44.
Do you have burning or cramping in your buttocks or hips after walking or exercising?
 YES NO 
45.
If so, does it subside with rest?
 YES NO 
46.
Do you ever get pain in your legs when you are standing or sitting?
 YES NO 
47.
Do you ever get pain in your legs when you walk up a hill or hurry?
 YES NO 
48.
Are your feet bright red in color?
 YES NO 
49.
Have you had loss of hair on your feet or toes?
 YES NO 
50.
Do you have irregular growth of toenails?
 YES NO 
51.
Are your toes pale, discolored or bluish?
 YES NO 
52.
Have you experienced temporary weakness of a leg on one side of the body?
 YES NO 
53.
Do you have pain in feet or toes at night?
 YES NO 
54.
Do you have leg/ankle/feet swelling?
 YES NO 
55.
Do you have painful varicose veins?
 YES NO 
56.
Do you have painful sores or ulcers on your legs or feet that are not healing?
 YES NO 
57.
Do you have skin changes in the lower legs such as discoloration or thickening?
 YES NO 
58.
Do you wear support stockings?
 YES NO 
59.
Do you have an open sore between your knee and ankle that took a long time to heal?
 YES NO 

Personal Information

Your Name:* 

 

Date of Birth:* 

 

Greenway ID#:* 

 

Appointment Date:* 

 

Phone Number:*
(xxx-xxx-xxxx)  - -

 

Done By:* 

 

If you answered YES to any of the above questions, and wish to provide further explanation, please do so here:

 

 

*required information