| Yes No | Do you or an immediate family member have cardiovascular (heart) problems such as high blood pressure, heart attack, or stroke? |
| Yes No | Do you or an immediate family member have diabetes? |
| Yes No | Do you have aching, cramping, or pain in your legs when you walk or exercise, but then the pain goes away when you rest? |
| Yes No | Do you have pain in your toes or feet at night? |
| Yes No | Do you have any ulcers or sores on your feet or legs that are slow in healing? |
| Yes No | Do you smoke? |
| Yes No | Have you ever smoked? |
| Yes No | Do you eat fried or fatty foods three times a week or more? |
| Yes No | Do you have high cholesterol? |
| Yes No | Do you have an inactive lifestyle? |