Assessment

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Heart Risk Assessment
Cardiovascular disease is America's number one killer. The following questions can help determine your risk for heart disease. Please take a moment to fill out the survey.

Accurate contact information below is required
for processing your personalized results.

Name
Address
City
State		Zip
Phone
E-Mail

Your Age: MEN	Your Age: WOMEN
Less than 35	Less than 35
35 - 44	35 - 44
45 - 54	45 - 54
55 - 64	55 - 64
65 plus	65 plus

Family History

Did an adult family member (parent, brother, or sister) have a heart attack, stroke, bypass surgery or angioplasty before age 60?
Yes
No
Unknown

Personal History

Has a physician ever told you that you have had a heart attack or have angina?
Yes
No

Stroke

Has a physician ever told you that you have had a stroke or have partially blocked blood flow to your head or legs?
Yes
No

Diabetes

Do you have diabetes? Yes No

Smoking

Do you smoke? Yes No

Physical Activity

Do you exercise three or more times a week (such as brisk walking, cycling, jogging, swimming, aerobic dance, active sports or heavy housework)?
Yes
No

Diet

Foods high in saturated fat or cholestorol include red meats, whole dairy, fried foods and deserts. What kind of food do you usually eat?
Eat high saturated fat foods most of the time
Eat high saturated fat foods often
Eat high saturated fat foods some of the time
Ususally eat low saturated fat foods

Blood Pressure

What is your blood pressure?
Below 130/85
130/85 - 139/89
140/90 or higher
Don't know

Cholesterol

What is your total cholesterol level?
<200 mg/dl
200 - 239 mg/dl
240 mg/dl or higher
Don't know

Stress

How would you describe the stress level in your life?
Very little
About average
Above average
Way too much

Weight

Are you more than 25 lbs. overweight?
Yes
No

Disclaimer: This questionnaire has been created for educational purposes only and should not be used as a substitute for professional medical advice, diagnosis, treatment, or care. Since health varies from person to person, not all recommendations and guidelines will be appropriate for every individual. If you have a particular health concern, contact your doctor and follow his/her recommendations regarding your specific medical needs.