Heart Disease Risk Assessment

According to the Centers for Disease Control and Prevention, heart disease is the leading cause of death in the U.S., affecting people of all ages and backgrounds. To help you determine if you are at risk, complete our online questionnaire and a health care professional will contact you.

1. Has an adult family member (parent or sibling) had a heart attack, stroke, bypass surgery or angioplasty before age 60?

2. Have you ever had a heart attack or experienced angina?

3. Have you ever had a stroke or experienced partially blocked blood flow to your head or legs?

4. Do you have diabetes?

5. Do you smoke?

6. Do you exercise regularly (minimum 30 minutes, three times a week)?

7. Do you consume foods high in saturated fat or cholesterol (this includes red meats, whole dairy, fried foods, etc.)?

8. Are you more than 25 lbs. overweight?

9. Do you consume alcohol on a daily basis?

10. Have you been diagnosed with high blood pressure?

In order to process your free heart disease risk assessment, please complete the information below so one of our health care professionals may assist you. Your personal information is confidential and will not be shared or used for any purposes other than this heart disease risk assessment.

General Internet communication is inherently not secure. For this reason, we highly recommend that data considered confidential or private in nature not be submitted on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)