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.

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















Yes
No

Yes
No

Sharp or stabbing pain
Burning
Pressure
Squeezing
Heartburn
Indigestion
Shortness of Breath
Smothering
Palpitations or racing
Other

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.

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.

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.

Very little
About average.
More than usual.
Way too much.

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.

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.

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.

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.


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