Heart Age Assessment Questionnaire Form
Complete this questionnaire to receive an assessment based on your lifestyle and health factors. All responses are confidential and no sensitive personal identifiers are collected.
What is your age group?
*
Please Select
Under 30
30-39
40-49
50-59
60-69
70 or older
What is your biological sex?
*
Male
Female
Prefer not to say
Do you currently smoke or use tobacco products?
*
Yes, regularly
Occasionally
No
How often do you engage in moderate physical activity (e.g., brisk walking, cycling)?
*
Daily
Several times a week
Once a week
Rarely or never
How would you rate your typical diet?
*
1
2
3
4
5
Do you have a family history of early heart disease (before age 60)?
*
Yes
No
Not sure
How often do you feel stressed or anxious?
*
Most of the time
Sometimes
Rarely
How would you rate your general health?
*
1
2
3
4
5
Please indicate your agreement with the following statements about your lifestyle.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I maintain a healthy weight
1
2
3
4
5
I limit processed and high-sugar foods
6
7
8
9
10
I get adequate sleep regularly
11
12
13
14
15
Is there anything else about your lifestyle you would like to share?
Submit Assessment
Should be Empty: