Vascular Risk Assessment

Please take a moment to evaluate your vascular health. Print this page and take it with you the next time you visit your physician.

1. Do you have pain in your calf, thigh or buttocks that begins when you walk and ends when you rest?
   Yes  /  No

2. Do you have a sore on your leg or foot that will not heal?
   Yes  /  No

3. Do you have loss of hair on the top of your foot or toes?
   Yes  /  No

4. Do you take blood pressure lowering medications?
   Yes  /  No

5. Do you have a history of diabetes?
   Yes  /  No

6. Do you or have you smoked for more than 10 years?
   Yes  /  No

7. Do you have a family history of diabetes or cardiovascular disease?
   Yes  /  No

8. Do you have or have you had a history of stroke, heart attack, congestive heart failure, narrowed coronary blood vessels, or narrowed arteries in the legs?
   Yes  /  No

9. Have you ever been told that you have high cholesterol blood levels?
   Yes  /  No

10. Do you take cholesterol-lowering medication?
    Yes  /  No

To learn more about your risks of vascular diseases talk to your doctor. To schedule a vascular and stroke risk assessment or to make an appointment with a doctor, call 1.877.UT.CARES (1.877.882.2737).