Questions   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
     

1. Do you have a family history (parents or siblings) of heart disease?

Yes  
No  
     

   
       

2. Do you have a family history of premature stroke or heart disease? (answer yes if your father or brother had a stroke before age 55 OR your mother or sister had a stroke before age 65)

Yes    
No    
       

     
       

3. Do you have a family history of other cardiovascular disease such as high blood pressure, congestive heart failure, sudden death, poor circulation in your legs, or arrhythmias? (answer yes if any are true)

Yes    
No    
       

     
       

4. Are you African American?

Yes    
No    
       

     
       

5. Do you have high cholesterol or take medication to treat high cholesterol?

Yes    
No    
       

     
       

6. Are you diabetic or do you currently take medication to treat diabetes?

Yes    
No    
       

     
       

7. Do you have high blood pressure (hypertension) or are you currently taking medication to treat high blood pressure? High blood pressure is defined as higher than 120/80.

Yes    
No    
       

     
       

8. Do you smoke, use tobacco products, or are you exposed to second-hand smoke on a daily basis?

Yes    
No    
       

     
       

9. Are you overweight or obese?

Yes    
No    
       

     
       

10. Are you age 45 or older OR have you already gone through menopause (natural or surgical)?

Yes    
No    
       

     
       

11. Do you exercise less than three days per week for less than 30 minutes each time?

Yes    
No    
       

     
       

12. Are you frequently under stress?

Yes    
No    
       

     
       

13. Are you over 35 AND taking birth control pills?

Yes    
No    
       

     
       

14. Do you have kidney disease or receive dialysis?

Yes    
No    
       

     
       

15. Have you ever been diagnosed with metabolic syndrome? **

Yes    
No    
       

     
       

** Metabolic syndrome is defined as having at least three of the following:

  • High blood sugar after fasting (>110 mg/dL)
  • High triglycerides (>150 mg/dL)
  • Low “good” cholesterol (>50 mg/dL for women; >40 mg/dL for men)
  • Blood pressure of 130/85 or higher
  • Waist measurement: 35 inches or greater for women; 40 inches or greater for men.