Please enter the following figures:

(Do your best to answer every question.  If you can, make an educated guess.  If you have no idea, leave the box blank.  Blank boxes are counted as none or a neutral score.)

Total Cholesterol    HDL     Triglycerides 

Systolic Blood Pressure     Diastolic Blood Pressure 

Fasting Blood Sugar 

Overweight (in pounds--if not overweight enter 0) 

Waist Measurement (actual measurement in inches, not pant size) 

Exercise Level (primarily aerobic, enter 1-5; 1=excellent; 3=average, 5=very poor) 

Stress/Tension Level (enter 1-5; 1=very low stress; 3=average, 5=very high stress) 

How Many Heart Attacks Have You Had? 

    How Many Years Ago Was Your Last Heart Attack? 

Been Diagnosed With Heart Disease or Had a Bypass or Angioplasty? (y/n) 

Symptoms of Angina Within Last Year?  (m=mild, mo=moderate, s=severe) 

Have you had a stroke? (y/n)

How many parents have had a heart attack before age 65? 

How many grandparents have had a heart attack before 65? 

Smoking (number of cigarettes, cigars or pipes per day--0 if none)

Second-hand smoke  (m=mild, mo=moderate, s=severe) 

If female, are you postmenopausal? (y/n) 

Age    Gender (m/f)                      

Name (not required, but it prints with your report)   

Would you like the Heart Risk Evaluations Diet and Recommended Reading List printed as part of your report? (y for Yes; n or blank for No)       

Physician Code (For registered physicians--prints physician information on report)