Cardiovascular and Lymphatic Systems Survey
Please complete this survey to help assess your cardiovascular and lymphatic health. Your responses are confidential and will assist in evaluating related health factors.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Do you have a family history of heart disease or lymphatic disorders?
*
Yes
No
Not sure
How often have you experienced the following symptoms in the past month?
*
Rows
Never
Rarely
Sometimes
Often
Always
Chest pain or discomfort
1
2
3
4
5
Swelling in legs or ankles
6
7
8
9
10
Shortness of breath
11
12
13
14
15
Unusual fatigue
16
17
18
19
20
Palpitations or irregular heartbeat
21
22
23
24
25
How would you rate your overall cardiovascular health?
*
1
2
3
4
5
How would you rate your overall lymphatic health?
*
1
2
3
4
5
Do you currently smoke or use tobacco products?
*
Yes
No
Former smoker
How often do you engage in physical activity?
*
Please Select
Daily
Several times a week
Once a week
Rarely
Never
Please use the scale below to indicate your agreement with each statement.
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am aware of the risk factors for cardiovascular disease.
26
27
28
29
30
I regularly check my blood pressure.
31
32
33
34
35
I am knowledgeable about symptoms of lymphatic disorders.
36
37
38
39
40
If you have any other symptoms, concerns, or relevant medical history, please describe them below:
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