Questions
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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.