Cardiovascular Risk Assessment Form
Please complete this form to help assess your risk for cardiovascular disease. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex Assigned at Birth
*
Male
Female
Other / Prefer not to say
Contact Email
example@example.com
Personal Medical History
*
High Blood Pressure (Hypertension)
High Cholesterol
Diabetes
Heart Attack or Stroke
None of the above
Other
Family History of Cardiovascular Disease
*
Yes, first-degree relative (parent, sibling, child)
Yes, second-degree relative (grandparent, aunt/uncle)
No known family history
Not sure
Lifestyle Factors
*
Rows
Smoking Status
Physical Activity
Diet Quality
Current
1
2
3
Former
4
5
6
Never
7
8
9
Alcohol Consumption
Never
Occasionally
Weekly
Daily
Recent Blood Pressure Reading (mmHg)
*
Recent Total Cholesterol (mg/dL)
*
Body Mass Index (BMI)
*
How would you rate your current stress level?
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Additional Comments or Information
Submit Assessment
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