| AGE |
|
56 years and older |
|
55 years and younger |
| SEX |
|
Male |
|
Post Menopausal |
|
Female |
| HEREDITY |
| Someone in your family (mother, father, sister or brother) had a heart attack, stroke or by pass surgery. |
|
Occured at or before age 59 |
|
Occured at or after age 60 |
|
Never occured or you do not know |
| MEDICAL HISTORY |
|
|
You have had a heart attack |
|
You have not had a heart attack, but have had a stroke, bypass surgery, angioplasty or blood vessel surgery. |
|
You have never had any of the above. |
| CIGARETTE TOBACCO USE |
| Do you smoke? |
|
Yes |
|
No |
| DIABETES |
| Are you diabetic? |
|
On insulin or pills |
|
Controlling diabetes by diet |
|
Not diabetic |
| CHOLESTEROL |
| Have you ever been told you have high cholesterol? |
|
Yes |
|
No |
| BLOOD PRESSURE |
| Have you ever been told you have high blood pressure? (A reading over 135/85 is considered high) |
|
Yes |
|
No |
| WEIGHT |
| Are you? |
|
More than 25 pounds overweight |
|
25 pounds overweight |
|
10 to 24 pounds overweight |
|
less than 10 pounds overweight/normal weight |
| STRESS |
| How well do the following words describe your personality? Competitive, bossy, easily angered, pressed for time. |
|
Very well |
|
Fairly well |
|
Not at all |
| EXERCISE |
| Do you participate in any activities such as brisk walking, bicycling, swimming, dancing for 15 - 20 minutes? |
|
Less than once a week |
|
One to two times a week |
|
More than three times per week |
|
