Heart Health Survey

(309) 624-7777
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Is Your Heart At Risk?
Cardiovascular risk factor analysis for Men

Fill out the following form, and we will contact you regarding your heart's health, and many ways to maintain a heart-healthy lifestyle!

Age
  Age: Over 75
  Age: 70-74
  Age: 65-69
  Age: 60-64
  Age: 55-59
  Age: 50-54
  Age: 45-49
  Age: 40-44
  Age: 35-39
  Age: 20-34

Blood Cholesterol Level (Please Choose Your Age)

Heart Information
Have you ever experienced any of the following?

A Stroke
A TIA (transient ischemic attack, mini stroke)
An episode of difficulty in speaking which subsequently resolved
An episode of loss of vision which subsequently resolved
An episode of arm or leg weakness which subsequently resolved
Blocked carotid (neck) arteries that cause symptoms?

Yes
No

An aortic aneurysm (dialated aorta)
An aortic dissection (tear in the aorta)

Yes
No

Recurrent thigh or calf pain when you walk
Blocked arteries in your legs that cause leg pain when you walk

Yes
No

Do you have diabetes mellitus which requires oral medication or insulin?
A myocardial infraction (heart attack)
Angina pectoris (chest pain)
Coronary artery bypass surgery
Coronary angioplasty (PTCA) or stent
Frequent chest or arm pain with exercise

  Yes
  No

HDL
What is your HDL ("good") cholesterol? If you do not know, please select 40-49.
  >60
  50-59
  40-49
  <40

Smoking
If you are a smoker
  I do not smoke
  Age 20-39
  Age 40-49
  Age 50-59
  Age 60-69
  Age 70 and up

Blood Pressure
Use the following to select your systolic blood pressure (top number). If you don't know, select 100 plus your age and select the appropriate choice.

I am NOT taking medication for this

    0-120 mm Hg
    120-129 mm Hg
    130-139 mm Hg
    140-149 mm Hg
    150 mm Hg and up

I AM currently taking medication for this

    0-120 mm Hg
    120-129 mm Hg
    130-139 mm Hg
    140-149 mm Hg
    150 mm Hg and up

Health Information
Have you ever been told any of the following?

That your cholesterol levels are elevated
That you have an elevated blood homocysteine level
That you have elevated high sensitivity C-reation protein level
That you have left ventricular hypertrophy
Did your father have a heart attack before age 45?
Did your mother have a heart attack before age 55?

  Yes
  No

Are you physically inactive?
  Yes
  No

Do you feel that you suffer from unusual levels of stress, anger, anxiety, and social isolation?
Do you suffer from depression?

  Yes
  No

Is your wrist circumfrence 40" or more?
  Yes
  No

Have you experienced any of the following?
Select the number that apply to you.

Have you ever been told that you have "borderline" diabetes or mildly elevated blood sugar levels?
Is your HDL ("good") cholesterol level <40?
Do you have high serum triglyceride level (>150)?
Is your systolic blood pressure > 120 mm Hg?
Is your diastolic blood pressure > 80 mm Hg?

  None
  One
  More Than One

Please Provide The Following Information

Name:	A value is required.
Phone:	A value is required.
Email	A value is required.

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