Healthy Heart Survey

Question:

Have you ever been diagnosed with any of the following: congestive heart failure (CHF), high blood pressure (hypertension), mitral valve prolapse, angina, or periodontal disease? Have you ever been diagnosed with coronary artery disease, or have you ever had a heart attack?

Question:

Is your blood pressure 135/90 or higher?

Question:

Have you ever been told you have high blood pressure (hypertension)?

Question:

Are you taking medication for high blood pressure (hypertension), have been told you should take medication for high blood pressure (hypertension), or are taking nutritional supplements for high blood pressure (hypertension)?

Question:

Have you been diagnosed with any of the following: periodontitis, muscular dystrophy, Parkinson's disease, Alzheimer's disease, cancer, diabetes?

Question:

Have you ever been diagnosed with congestive heart failure (CHF)?

Question:

Are you scheduled for heart surgery?

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Do you use an antidepressant (such as amitripyline, amoxapine, clomipramine, desipramine, doxepin, imipramine, nortriptyline, or perphenazine)?

Question:

Do you have angina?

Question:

Have you ever had a heart attack?

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Are you taking a statin drug or red yeast rice?

Question:

Do you suffer from migraines?

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Have you had intestinal surgery, suffer from Crohn's disease, irritable bowel syndrome (IBS), ulcerative colitis, or cystic fibrosis?

Question:

Have you been diagnosed with atherosclerosis, arteriosclerosis, or hardening of the arteries?

Question:

Do you have high cholesterol? Have you had a blood test that showed high cholesterol (LDL)? Is your total cholesterol level 240 mg/dL or higher?

Question:

Have you had a blood test that showed low good cholesterol (HDL)?

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Have you had a blood test that showed you have high or elevated triglycerides?

Question:

Have you been diagnosed with chronic venous insufficiency or varicose veins?

Question:

Have you been diagnosed with intermittent claudication?

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Do you have platelet aggregation, have had a stroke, or are at risk for a stroke?

Question:

Have you been diagnosed with a heart arrhythmia, an irregular heart beat, or an abnormal heartbeat?

Question:

Have you been diagnosed with diabetes, hypoglycemia, or take medicine to control your blood sugar?

Question:

Do you suffer from depression?

Question:

Do you suffer from fibromyalgia?

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Do you find it difficult to lose weight?

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Do you have iron deficiency anemia?

Question:

Do you have ischemic heart disease?

Question:

Do you have cardiomyopathy or an enlarged heart?

Question:

Does your blood work show an elevated fibrinogen?

Question:

Does your blood work show an elevated C-reactive protein?

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Does your blood work show high homocysteine levels (hyperhomocysteinemia)?

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Are you taking Angiotensin-converting enzyme (ACE) inhibitor, such as captopril (Capoten), enalapril (Vasotec), and lisinopril (Prinivil, Zestril) and have developed a cough.

Question:

Do you have peripheral vascular disease?

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Are you a male older than 55 or a female older than 65?

Question:

Is there a family history of heart disease? Did your father or brother have a heart attack before age 55 or your mother or sister had one before age 65?

Question:

Would you consider yourself sedentary or inactive (you don't accumulate at least 30 minutes of physical activity on most days of the week)?

Question:

Have you ever been diagnosed with a diminished ejection time or told you have damage to the muscle of the heart which has impaired the heart's ability to eject blood, or been told you have a reduced ejection fraction?

Question:

Do you feel stressed out often?

Question:

Do you have difficulty falling asleep, do you toss and turn, or do you wake up feeling tired and not well-rested? Have you been told you have, or have you been diagnosed with sleep apnea?

Question:

Do you have asthma?

Question:

Are you 20 pounds or more overweight?

Body Mass Index

Your Height: (feet) (inches)

Your Weight: (pounds)