Part A : Personal Health History
Sex :
Male
Female
Age :
Height :
Weight :
Race/Ethnicity :
Enter your First Name only :
Phone Number :
Email :
State/Country :
Do you have health Insurance? :
Yes
No
Do you have a primary care physician? :
Yes
No
Blood pressure: Indicate your usual blood pressure.
Systolic Pressure ( High number) :
Less than 120
120- 140
140 – 160
Above 160
Don’t Know
Diastolic Pressure ( Low number) :
Less than 80
80- 90
Above 90
Don’t Know
Are you now taking prescribed medication for your blood pressure? :
Yes
No
Total Cholesterol level (Indicate your usual total blood cholesterol level) :
Below 160
160 – 199
200 – 239
240 – 279
280 or above
Don’t Know
Are you now taking prescribed medications for your cholesterol? :
Yes
No
Good Cholesterol level (HDL): Indicate your usual HDL blood cholesterol level :
Below 40
40 – 49
50 – 59
Above 60
Don’t Know
Bad Cholesterol level (LDL): Indicate your usual HDL blood cholesterol level :
Below 100
100 – 149
150 – 200
Above 200
Don’t Know
Triglycerides Cholesterol level :
Below 100
100 – 149
150 – 200
Above 200
Don’t Know
Have you ever been told by a doctor that you have diabetes? :
Yes
No
Are you now taking prescribed medications for your diabetes? :
Yes
No
Have you ever been told by a doctor that you have heart disease? :
Yes
No
Smoking Status :
I never smoked
Quite Smoking 2 or more years ago
Quite Smoking Less that 2 years ago
Currently Smoking Less that 10 Cigarettes Daily
Currently Smoking more than 10 Cigarettes Daily
Family heart history: Did a parent, brother, or sister ever have coronary heart disease, heart
Yes
No
If you were to have a heart attack in the next 10 years, which of the following factors would be
Part B : Demographics
Directions: Please read each of the following statements and fill in the blanks or select the answer
Marital Status :
Single
Married
Living with Husband/Partner? :
Yes
No
Total number of years of education from first grade Present Employment Status
Retired
Homemaker
Student
Full-time (35+ hours a week)
Part-time (less than 35 hours a week)
Unemployment
Current household income :
$15000 or less
$15001 - $25,000
$25,001 - $45,000
$45,001 - $60,000
$60,001 - $75,000
$75,001 - $90,000
$90,001 - $115,000
$115,001 - $200,000
$200,001 - $250,000
Security Code:
