Peripheral Artery Disease

Peripheral Artery Disease Screening

Welcome to the Peripheral Artery Disease Screening Program. This screening is for Peripheral Artery Disease (PAD), carotid artery (large blood vessels in your neck) disease and abdominal aortic aneurysm (AAA, the large artery in your abdomen). This program will give you information on these areas and screen you for possible problems. The screening process is very simple. A certified vascular technologist will take blood pressures in your arms and ankles for PAD screening, perform an ultrasound of your carotid arteries (neck) and abdominal aorta (stomach area), and ask you questions about your health. You may participate in any or all of these areas.

To register for a PAD screening, you can either call us directly at 814-877-5265, or you can fill out the questionnaire below. The information on it will go straight to our staff, who will contact you to set up an appointment.

The information below, as well as the answers to the questions on the questionnaire, will help us in this screening. The screening will determine if you are at high, moderate, low or no apparent risk for the problems for which you are being screened. If the screening indicates that you have risk factors, you will be told to see your doctor for an evaluation. You will have the opportunity to have the results from this screening sent to your doctor. You will also receive a copy of your results on the day of your screening.

Please fill out the information below:

Basic Information

Name

Address

City

State

Zip Code

Phone

Age

Birth Date

Sex

Male Female

Please answer the following questions

Have you ever been screened before?
(A diagnostic test is not a screening)

Yes No

If so, where?

Do you or anyone in your immediate family suffer from heart disease or PAD?

Yes No

Do you know your cholesterol?

Yes No

If so, please fill in:

HDL
LDL
Trigylcerides

Are you currently using cholesterol medication?

Yes No

If so, what kind and for how long?

Primary Care Physician

Please send my final screening results to my Primary Care Physician?

Yes No

Have you ever been to UPMC Hamot for treatment?

Yes No

How did you hear about the screening?

Physician Referral
Word of Mouth
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UPMC Hamot will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. We do not sell or rent personal information about visitors or patients who use the site.

You will receive a call within two business days to schedule your screening.

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