Have you had a heart attack, an angioplasty or stent, or coronary artery bypass surgery?
Yes No

Have you had a stroke or been told you have blockages in other arteries in your body such as the carotids, renals or arteries in your legs?
Yes No

Do you have diabetes or fasting higher than 110 mg./dL?
Yes No Don't Know

Major Cardiovascular Risk Factors

Are you a male over 45 years old or a female over 55 years old or experienced menopause?
Yes No

Do you have family members that developed heart disease at a young age? (Father or brother under 55 years old or mother or sister under 65 years old.)
Yes No Don't Know

Have you smoked cigarettes in the past 12 months?
Yes No

Select the numbers that most closely match your last blood pressure (BP) reading.

Is your systolic BP (top number) 140 or above?
Yes No Don't Know

Is your diastolic BP (bottom number) 90 or above?
Yes No Don't Know

Are you on medicine to lower blood pressure?
Yes No

Select the numbers below that most closely match your last lipid profile.

LDL Cholesterol:2
Less than 100 100-129 130-160 161-190 over 190 Don’t know

HDL Cholesterol:
Less than 40 Between 40 and 60 Greater than 60 Don’t know

Contributing Cardiovascular Risk Factors

Is your body mass index (BMI) 25 kg/m2 or greater?
Yes No

BMI= (weight in pounds/(height in inches x height in inches)) x 703

Are you exercising less than 30 minutes three times a week?
Yes No

Do you frequently have strong feelings of anger/hostility, stress or depression?
Yes No