Name

Address

City

State

Zip

Phone

Email

Primary Care Physician

Age

Date of Birth

Please answer the following questions:

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 diabetes?

3. Do you smoke?  Have you ever smoked?


Quit Date: 

4. Do you have high cholesterol?

5. Do you exercise at least 30 minutes per day?

6. Do you have a history of depression?

7. Do you feel anxious or stressed on a daily basis?

8. Are you overweight?

9. Do you have a history of high blood pressure?

10. Has it been at least one year since your last period (post-menopause)?