Cardiac Risk Factors Assessment Tool
Phone: 301-877-4661
DO NOT MAKE TIME TO BE SICK LATER,
MAKE TIME TO STAY HEALTHY NOW.
1. Weight
Do you consider yourself more than 20 pounds over
your ideal weight? qYes qNo
2. Blood Pressure
Do you have a history of high blood pressure? qYes qNo
Blood Pressure Reading:________
3. Diabetes
Do you have diabetes? q Yes qNo
Glucose Reading:_______
4. Cholesterol
Do you have a history of high Cholesterol? q Yes qNo
Cholesterol Reading:_______
5. Exercise
Do you exercise qregularly qperiodically qnever
Triglycerides Reading:________
6. Smoking
Do you smoke? q Yes qNo
7. Stress
Do you manage your stress well? q Yes qNo
8. Family history
Do you have a family history of heart disease? q Yes qNo
If you answered yes to 2 or more of the above questions, you may be at risk of developing cardiac disease.
Please contact our CardiacRiskReductionCenter at 301-877-4661 for additional information on this subject or to set up an appiontment.
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