1

Weight (kg)

2

Height (m)

3

Waist circumference (cm)

4

Hip circumference (cm)

5

Cyanosis Yes = 1, No = 2

6

Icterus Yes = 1, No = 2

7

Digital clubbing present Yes = 1, No = 2

If yes, state grade

8

Peripheral oedema Yes = 1, No = 2

9

Pulse rate (beats/min)

Pulse rhythm 1 = Regular, 2 = Regular + frequent ectopics, 3 = Regular + frequent ectopics, 4 = Regular + irregular, 5 = Irregular + irregular, 6 = Other

If other, specify

Pulse volume 1 = Small, 2 = Moderate, 3 = Large

Arterial wall texture 1 = Normal, 2 = Hard/tortuous, 3 = Not felt

Locomotor brachialis palpable? Yes = 1, No = 2

Volume of main peripheral pulses. 1 = Normal, 2 = Reduced, 3 = Absent, 4 = Increased

Symmetry of main peripheral pulses 1 = Equal, 2 = Unequal

Specify arteries affected