Heart Health Assessment
Please complete this assessment to help evaluate your current heart health and identify potential risk factors.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other / Prefer not to say
Height (cm)
*
Weight (kg)
*
Do you have any of the following conditions? (Select all that apply)
*
High blood pressure (hypertension)
High cholesterol
Diabetes
Heart disease
None of the above
Other
Do you have a family history of heart disease?
*
Yes
No
Not sure
How often do you engage in physical activity (at least 30 minutes)?
*
Daily
3-5 times a week
1-2 times a week
Rarely or never
How would you rate your diet in terms of heart health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Please indicate how often you experience the following symptoms:
*
Rows
Never
Occasionally
Frequently
Always
Chest pain or discomfort
1
2
3
4
Shortness of breath
5
6
7
8
Unusual fatigue
9
10
11
12
Swelling in legs or ankles
13
14
15
16
Do you smoke or use tobacco products?
*
Yes, currently
Used to, but quit
Never
Please share any additional information or concerns about your heart health:
Submit Assessment
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