Peripheral Arterial Disease Risk Modification Pathway

Referrals from vascular surgery Tallaght Hospital ONLY. All other referrals should be submitted via the Vascular Surgery Clinic pathway.

Please print a copy of the Intermittent Claudication advice sheet and Peripheral Arterial Rehabilitation clinic Information leaflet and give to the patients who are being referred.

Patient name:*
Patient MRN:*
Patient Age:
Patient phone number:
Referred by:*

Risk factors

Risk factors:

* Diabetes Type 1 (Insulin only); Type 2 (oral hypoglycaemics +/- insulin); Impaired Glucose tolerance (no medication)

Smoking Current smokers include those smoking within the last 30 days  

Previous cardiac or medical history:
Peripheral Arterial disease history and intervention:
Claudication distance (M):
ABI (right)
ABI (left)
TBI (right)
TBI (left)

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