Heart Risk Assessment Quiz
This Heart Risk Assessment is a 10 question quiz that will assess your potential for heart disease. After submitting the completed form it will be scored and your results will be displayed.

Demographics         Entries marked with an * are required

Name: *
Address 1:
Address 2:
City:
State: (US & Canada) *
Zip Code:
EMail Address: *
Telephone:
Do you have a cardiologist? * No   Yes

The Heart & Vascular Center of Arizona respects your privacy.   We will not disclose, sell, share, or rent any of your demographic information (name, address, EMail address, telephone number, etc.) that you have entered.

Age
What age group are you in?
34 or younger
35 to 50
51 or older

Family History
Mother, father, sister, or brother have a history of heart problems?
None or Do Not know
Heart Disease, Heart Attack, Stroke, By-Pass Surgery, Stents,                Balloon Angioplasty,

Personal Health History
Have you had any history of heart problems?
No history of heart problems
Angina, Stroke, By-Pass Surgery, Balloon Angioplasty, Stents
Heart attack

Smoking
Have you ever smoked?
Never smoked or quit smoking more than two years ago
Quit smoking less than two years ago
Current smoker

Blood Pressure
How is your blood preasure?
Normal or don't know
Treated for High blood pressure
Have High blood pressure

Exercise
Aerobics, brisk walking, swimming, jogging, or riding a bike
3 or more times per week
1 or 2 times per week
Less than 1 time per week

Diabetes
Borderline diabetic or active diabetes?
No
Yes

Body Mass
Height    
Is your weight at or below this weight for your height?
Is your weight above this weight for your height?

Blood Fat
Score your last cholesterol level or the amount of fat in your diet
Less than 200 mg/dl
200 - 240 mg/dl
Greater than 240 mg/dl
HDL good cholesterol less than 40
    OR
Low fat diet - very little or no red meat
Moderate fat diet - Fast food, high fat fried foods 4 to 7                  times/week or more than 4 eggs/week
High fat diet - Fast food daily and more than 7 eggs/week

Leg Pain
Do you experience leg pain when walking or exercising?
None
Pain in leg(s) starts and/or increases with walking or exercise

       

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