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Peripheral Artery Disease (PAD) Patient Progress Tracker

Daily Symptom and Activity Monitoring Sheet

Cardiology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: ___________________ Physician: _______________ Contact: ______________________

Daily Symptom Log

Pain/Discomfort Scale (0-10)

Date At Rest During Walking After Exercise Duration

Walking Distance

  • Maximum distance before pain: _______ feet/meters
  • Time walked before stopping: _______ minutes
  • Total daily walking time: _______ minutes

Circulation Check

Daily Leg Assessment

  • Color changes
  • Temperature differences
  • Swelling
  • Skin changes

Pulse Check Locations

  • Top of foot (dorsalis pedis)
  • Behind ankle (posterior tibial)

Rate pulse strength (0-3): _______

Lifestyle Factors

Blood Pressure Readings

Morning: / Evening: /

Daily Activities

  • Smoking: Yes___ No___ (Number of cigarettes: ___)
  • Exercise completed: ________________
  • Medication adherence: Yes___ No___

Weekly Goals

  1. Walking distance target: _______
  2. Exercise sessions planned: _______
  3. Dietary modifications: _______

Notes

*Contact your healthcare provider if you experience:

  • Severe pain at rest
  • New ulcers or sores
  • Significant color changes
  • Unusual coldness in legs/feet

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