General Information
The Venocuff II
Diagrams
Physician Enquiry
Distributor Enquiry
Patient Enquiry
Trial Screening Enquiry
H.E.L.P™ Clinical Trial Screening Form
For the prevention of lower limb amputation
Patient Recruitment
Demographics
Name:
Date of Birth:
Contact Details
Address:
Phone:
Mobile:
email:
Are you interested in receiving information regarding investment opportunities.
Medical History
Current GP
Current Diabetes Specialist
Name:
Address:
Phone:
Name:
Address:
Phone:
Current Vascular Surgeon
Other current medical professional
Name:
Address:
Phone:
Name:
Address:
Phone:
Do you have any diagnosed vascular diseases or lower limb problems?
Abdominal Aortic Aneurysm (AAA)
Diabetes
Peripheral Arterial/Vascular Disease
Neuropathy
Varicose veins or venous disease
Arthritis
Lymphatic problems
Has your Doctor ever said you have arterial disease or atherosclerosis in you legs?
No
Yes
Duration
Have you previously had any of these treatments?
Balloon angioplasty
Bypass grafting in your leg
A metal stent placed in your leg
Sympathectomy
What are your current symptoms?
Signs and symptoms
Duration
Cold feet or legs
years
Very dry, scaley, thin skin on your legs
years
Ulcers or poorly healing wounds on your legs
years
Pain when you walk
How far can you walk before the pain begins
< 10m
10 - 50m
50 - 100m
> 100m
Leg pain when you are resting or at night
(not when exercising/walking)
years
