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Thanks for assessing your heart disease risk. We will contact you soon
What is your name?
First and Last Name
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What is your age
Are you 40 or older?
YES
NO
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Gender
Are you male or female?
MALE
FEMALE
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Ethnicity
Are you
Asian
Mixed Race
Black
White
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Risk Factors
Do you have any of the following risk factors?
I have been diagnosed or have a preliminary diagnosis of heart disease
There is a history of heart disease running in my family
High cholesterol
Extra weight
High blood pressure
Light-headedness or fainting
None of the above
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Symptoms
Do you have any of the following symptoms?
I have been referred to see a cardiologist
Chest pain
Shortness of breath
Palpitations: The feelings of having a fast-beating, fluttering or pounding heart usually felt in the chest or the neck
No
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Menopause
Have you been through menopause?
YES
NO
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High blood pressure or diabetes
Have you had pregnancy-related high blood pressure or diabetes during pregnancy?
YES
NO
I have never been pregnant
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Chest Pain
What describes your chest pain best?
It suddenly occurs and lasts more than 15 minutes
The pain spreads into your arm, neck, jaw, back or stomach
You feel sick and sweaty
The chest pain comes and goes and you forget about it
The chest paint comes and goes away quickly and leaves you feeling worried
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Shortness of breath
When do you experience shortness of breath?
During everyday activities (e.g. walking up stairs, carrying shopping bags, etc.)
During exercise
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During exercise
Do you exercise frequently?
Yes, about 3-4 times a week
No, I don't exercise frequently
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Palpitations
Do you...
Smoke
Drink alcohol
Drink caffeinated drinks
Feel stressed or anxious
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No Symptoms
Which of these statements apply to you?
I'm health conscious
I participate in physically demanding activities (e.g. marathon, bike race, power lifting, etc.)
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Thanks for assessing your heart disease risk
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