Cartersville Medical Center

Heart Risk Assessment

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Heart Risk Assessment

Know Your Risks... Complete the Heart Risk Assessment Today

The following questions can help determine your risk for heart disease. Please take a moment to fill out the survey. When you have completed the entire assessment, click on the submit button at the bottom of the page. Results will be sent to you by mail in a few weeks.

Required Fields *

Name^* : Address:^* City:^* State:^* Zip:^*

Please provide the following so we may contact you about your results

Phone:^* Email:^*

Birthday (MM/DD/YYYY):

Height^*

Weight:^*

Race/Ethnicity:^*

What is your:
HDL (good):^*

LDL (bad):^*

Do you have a history of heart disease?

Yes

Are you having any discomfort of the chest, arms, or neck?

Yes

Are you having any discomfort of the chest, arms, or neck?

Sharp or stabbing pain

Burning

Pressure

Squeezing

Heartburn

Indigestion

Shortness of Breath

Smothering

Palpitations or racing

Other

How do you describe your family history of heart disease or stroke?

No one is my close family (parents, grandparents, brother or sisters).

One or more of my close family has had a heart attack or stroke before age 60.

Members of my close family have had heart attacks or strokes, only after age 60.

How do you describe your family history of heart disease or stroke?

I watch my diet closely and eat healthy, low-fat meals.

I usually try to eat healthy, but on occassion slip up.

I would like to eat healthy, but often don't.

I make no attempt to eat a healthy diet.

How do you describe your physical activity?

I exercise for at least 30 minutes, five days a week.

I exercise for at least 30 minutes, two to four days a week.

I do not exercise.

How do you describe the stress in your life at present?

Very little

About average.

More than usual.

Way too much.

How do you describe your cholesterol level?

I do not know what it is.

I have been told it is normal.

I have been told it is a little too high.

I have been told it is clearly too high, but am not on medicaiton.

I have been told it is clearly too high, and am on medicaiton to lower it.

How do you describe your smoking habit?

I have never smoked.

I quit smoking in the past 6 months.

I quit smoking more than 6 months ago.

I smoke less than two packs per day.

I smoke more than two packs per day.

How do you describe your diabetes?

I do not have diabetes.

I have diabetes that I control with diet.

I have diabetes and take pills to treat it.

I have diabetes and take insulin to treat it.

I have diabetes, but don't do anything to treat it.

I do not know if I have diabetes.

How do you describe your blood pressure?

I don't have high blood pressure.

I have high blood pressure, but am not on medication.

I have high blood pressure and am on medication to lower it.

I don't know if I have high blood pressure.

For Women Only
How do you describe your menopausal/hormone status?

I am pre-menopausal and take no hormone or birth control pills.

I am post-menopausal and take no hormone or birth control pills.

I am post-menopausal and take hormone or birth control pills.

I am not sure of my menopausal status, but I take no hormone or birth control pills.

I am not sure of my menopausal status, but I take hormone or birth control pills.

Please enter this word in the text field below, then click Submit.

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Cartersville Medical Center

Heart Risk Assessment

Know Your Risks... Complete the Heart Risk Assessment Today

Your Health