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Heart health assessment tool

Determining your personal risk factors is the first step toward awareness and ultimately the prevention of heart disease. To each of the questions listed below, find the answer that best applies to your personal situation. Once complete, go over the answers with your family physician. Together, you can determine your personal risk factors and how to best address them.

  1. Did your parents or siblings ever have coronary heart disease, a heart attack or coronary surgery (men before age 55 or women before age 65)?    
  2. Is there any history of high blood cholesterol in your family?
  3. Do you have diabetes?
  4. Have you ever had a heart attack?
  5. Do you currently have coronary heart disease, angina or congestive heart failure?
  6. If yes, are you currently taking medication for your heart condition?
  7. Have you ever had a stroke?
  8. Have you currently experience restricted blood flow to your head or legs?
  9. If yes to question seven or eight, are you currently taking medication for your condition?
  10. How many days of the week do you participate in at least 20 to 30 minutes at one time of aerobic exercise (i.e. walking, cycling, swimming, jogging, aerobic dance or active sports)?
                           --one day weekly
                           --two days weekly
                           --three days weekly
                           --four days weekly
                           --five days weekly
                           --six days weekly
                           --every day
  11. Indicate the kinds of foods you usually eat.
    High saturated fat examples: hamburgers, hot dogs, bologna, sour cream, cheese, whole mile, eggs, butter, high caloric deserts, candy, fast foods.
    Low saturated fat examples: lean meats, skinless poultry, fish, skim milk, fruit, gelatin desserts, vegetables, pasta
                           --I always eat the high saturated fat foods
                           --I mostly eat the high saturated fat foods
                           --I eat both the high and low saturated fats about the same
                           --I eat mostly low saturated fat foods
                           --I eat only low saturated fat foods
  12. How often do you add salt to your food or eat already salty foods such as chips, pickles or soy sauce?
                          --seldom or never
                          --some meals
                          --most meals
                          --every meal
  13. How many alcoholic drinks, such as wine, beer or liquor do you usually have per week? (One drink is 12 oz. of beer, five oz. of wine or 1.5 oz. of hard liquor)
                          --one to six
                          --seven to 13
                          --14 to 20
                          --21 or more
  14. Indicate your smoking status.
                         --never smoked
                         --quit smoking two or more years ago
                         --quit smoking less than two years ago
                         --currently smoke a pipe or cigar
                         --currently smoke less than 10 cigarettes daily
                         --currently smoke 10 or more cigarettes daily
  15. Are you exposed regularly to second hand smoke at home or work?
  16. Indicate your usual blood pressure
                        --less than 130/85
                        --140/90 or higher
                        --don't know
  17. Indicate your usual blood cholesterol
                        --180 or below
                        --181 - 199
                        --240 or higher
                        --don't know
  18. Are you currently taking birth control pills?
  19. Have you reached or passed menopause either naturally or through surgery or other treatment?
  20. Are you currently taking estrogen or any other female hormone?
  21. How well do you feel you are coping with stress?
                       --very well
                       --fairly well
                       --have trouble coping at times
                       --often have trouble coping
                       --feel unable to cope anymore
  22. During the past four weeks, have you been a happy person?
                       --all the time
                       --most of the time
                       --a good bit of the time
                       --some of the time
                       --a little of the time
                       --none of the time
  23. Have you thought about making lifestyle changes?
                       --haven't thought about changing
                       --plan a change in the next six months
                       --plan to change this month
                       --recently started doing this
                       --do this regularly (last six months)
  24. How ready are you to make changes to your lifestyle in the following areas?
                       --to be physically active most days
                       --to eat mostly healthy foods
                       --live smoke and tobacco free
                       --achieve and maintain a healthy weight
                       --handle stress well
                       --drink alcohol moderately if at all
                       --live an overall healthy lifestyle

Learn the state of your heart and what you can do to live a better life with the American Heart Association's My Life Check calculator. You'll get immediate results by answering a few simple questions.

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