Heart Attack Assessment Form
Use this form to assess current heart-attack-related symptoms, risk factors, and urgency so the appropriate next steps can be identified.
Symptom Assessment
Chest pain or discomfort
*
Yes
No
Unsure
Pain spreading to arm, jaw, or back
*
Yes
No
Unsure
Shortness of breath
*
Yes
No
Unsure
Sweating or clammy skin
Yes
No
Unsure
Nausea or vomiting
Yes
No
Unsure
Dizziness or lightheadedness
Yes
No
Unsure
Palpitations or irregular heartbeat
Yes
No
Unsure
Symptom severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Risk Factors and Medical History
Age
*
Sex at birth
*
Female
Male
Intersex
Prefer not to say
Known medical conditions
*
High blood pressure
High cholesterol
Diabetes
Heart disease
Prior heart attack
None of the above
Other
Smoking or vaping status
*
Never
Former
Current daily
Current occasionally
Prefer not to say
Family history of heart disease
No
Yes, in a parent or sibling
Yes, in another close relative
Unknown
Current medications related to heart health
Recent strenuous activity or major stress before symptoms
No
Yes, strenuous physical activity
Yes, emotional stress
Yes, both
Unknown
Other relevant medical history
Urgency and Follow-Up
When did the symptoms start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Are you currently alone?
*
Yes
No
Have emergency services already been contacted?
*
Yes
No
Can you safely wait for a callback?
*
Yes
No
Not sure
Preferred contact method for follow-up
Please Select
Phone call
Text message
Email
No follow-up needed
Current location or setting
Submit Assessment
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