Primary Care Physician
Date of Birth
Please answer the
1. Do you have a family history of heart
disease? (parents/brother/sister/grandparent heart attack under age 60)
2. Do you have high blood sugar or
3. Do you smoke? Have you ever
4. Do you have high cholesterol?
5. Do you exercise at least 30 minutes per
6. Do you have a history of depression?
7. Do you feel anxious or stressed on a
8. Are you overweight?
9. Do you have a history of high blood
10. Has it been at least one year since
your last period (post-menopause)?