Atherosclerosis Assessment Survey
Please complete this survey to help assess your risk factors and symptoms related to atherosclerosis.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Do you have a family history of heart disease?
*
Yes
No
Not sure
Have you been diagnosed with any of the following conditions? (Select all that apply)
*
High blood pressure (hypertension)
High cholesterol
Diabetes
Obesity
None of the above
Lifestyle Habits
*
Rows
Never
Rarely
Sometimes
Often
Always
Smoke tobacco
1
2
3
4
5
Consume alcohol
6
7
8
9
10
Eat a diet high in saturated fat
11
12
13
14
15
Exercise at least 3 times a week
16
17
18
19
20
How would you rate your stress level in daily life?
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
In the past month, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Chest pain or discomfort
21
22
23
24
25
Shortness of breath
26
27
28
29
30
Fatigue during activity
31
32
33
34
35
Numbness or weakness in limbs
36
37
38
39
40
Do you currently take any medication for blood pressure, cholesterol, or diabetes?
*
Yes
No
Please provide any additional relevant information or concerns regarding your cardiovascular health.
Submit Assessment
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