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Heart Health Assessment

It is always best to discuss your individual health directly with your healthcare provider. Talk with your doctor if you have questions or concerns about the information presented in this assessment.

IMPORTANT: If you think you are having a heart attack, call 911 immediately! Then chew or crush an aspirin, as directed by your doctor, to increase your chance of survival and decrease damage to your heart.

Recognize the signs of a heart attack:

Chest discomfort: Uncomfortable pressure, squeezing, fullness, or pain in the center of the chest that lasts for several minutes. Or, it goes away and comes back.
Discomfort in other areas of the upper body: Can include pain or discomfort in one or both arms, back, neck, jaw, or stomach.
Shortness of breath: May come with or before chest discomfort.
Other signs: May include cold sweat, nausea or lightheadedness.

Personal Information

 

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AGE & SEX

FAMILY HISTORY

(Please check all that apply.)

BLOOD PRESSURE

TOBACCO SMOKE

PHYSICAL ACTIVITY

TOTAL CHOLESTEROL

DIET

(Please check all that apply.)

DIABETES

HEART DISEASE & STROKE

(Please check all that apply.)

DOCTOR

STRESS LEVEL

ALCOHOL