Cardiovascular Risk AssessmentFirst NameLast NameEmailGender Male FemaleHow old are you? Male younger than 55 years old Female younger than 65 years old Male at least 55 years old Female at least 65 years oldFamily History? Yes NoWaist Circumference Woman Less than 35 inches Man Less than 40 inches Woman 35 inches or more Man 40 inches or moreWhat’s your weight range according to BMI? Underweight Average Overweight ObeseWhat is your resting pulse? Less than 60 beats per minute Less than 75 beats per minute More than 75 beats per minute Don’t knowWhat is your blood pressure? Less than 120/80 120/80 to 139/89 140/90 or higher Don’t know I take blood pressure medicationWhat is your total cholesterol level? Less than 160 mg/dL Less than 200 mg/dL Greater than 200 mg/dL Don’t know I take cholesterol medicationWhat is your HDL (good) cholesterol level? Woman Less than 60 mg/dL Man Less than 50 mg/dL Woman 60 mg/dL or higher Man 50 mg/dL or higher Don’t knowWhat is your LDL (bad) cholesterol level? Less than 70 mg/dL Less than 70 mg/dL 70 to 99 mg/dL 100 to 130 mg/dL More than 130 mg/dL Don’t knowWhich best describes your triglyceride level? Less than 100 mg/dL 101 to 150 mg/dL More than 150 mg/dL Don’t knowDo you have diabetes or high blood sugar? No Yes, I’m prediabetic Yes, I’m prediabetic Yes, I’m diabetic I haven’t been testedDo you have bleeding gums? Yes NoWhich best describes your sleep patterns? I sleep soundly 6–8 hours a night I sleep restlessly for 6–8 hours a night I sleep less than 6 hours or more than 9Do you snore? No Yes, occasionally Yes, frequently and loudly Yes, and I have sleep apneaDo you have rheumatoid arthritis or other inflammatory disease? Yes NoWhat is your vitamin D level? At least 50 ng/ml 30 to 49 ng/ml Less than 30 ng/ml I do not know my vitamin D levelDo you have a history of migraines? No Yes, with no migraine aura Yes, with a migraine auraHow would you characterize your ability to cope with stress? I’m usually pretty laid back I have healthy ways to cope with stress Sometimes people say that I seem stressed I feel stressed and anxious most of the timeDo you spend 11 or more hours a day sitting? Yes NoHow much exercise do you get? At least 30 minutes, 5–7 days per week At least 30 minutes, 2–4 times per week 30 minutes, once a week or less I do not exerciseDo you use nicotine? No Yes, but have quit for at least 5 years Yes, but quit less than 5 years ago No, but I am exposed to secondhand nicotine regularly YesDo you drink soft drinks? Never Rarely drink soft drinks Once a week More than once a weekDo you watch the amount of carbohydrates in your diet? I limit my simple carbohydrate intake I know how to balance my carbs and proteins I never watch my carbohydrates The majority of my diet consists of carbs(Women Only) Pregnancy Complications Yes No(Men Only) Erectile Dysfunction Yes NoSubmit Form
