Please take a moment to fill out this questionnaire and inform yourself about your health. Take your time and be sure to answer all the questions or your results will be inaccurate.

First, please answer questions about the five major factors contributing to heart disease.

1. Do you have high blood pressure? Yes and I take medication for it Yes and I control it with diet No 2. What is your cholesterol level? Less than 200 Between 200 and 239 Over 239 3. Do you have diabetes? No Yes, but it is controlled with diet Yes 4. Do you smoke? If yes, how much? No (Never, or I quit more than 2 years ago) No (But I quit less than two years ago) Yes, less than a pack a day Yes, more than a pack a day 5. Is there a history of heart disease in your family? No Yes, younger than 50 Yes, older than 50

Now please answer some questions about the five minor factors contributing to heart disease.

6. How many times a week do you exercise for twenty minutes? None 1-3 times 3 or more times 7. Are you overweight? More than 25 pounds overweight 10 to 25 pounds overweight Less than 10 pounds overweight 8. What is your gender? Male Female 9. How old are you? Under 25 25-50 51 or above 10. Do you have a type A personality? In other words, do you get tense and aggravated easily? No Borderline Yes

Note--This test is designed to give you a general idea of what your risk for heart disease is. It is not meant to take the place of a visit to a physician. If you have concerns about the condition of your heart, please contact a cardiologist as soon as possible.