Heart Risk Quiz

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

Save and Resume Later

Save and get link

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

Apply Discount

You saved

with code

Submit Form

Submitting

Validating

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Please check the field:

Fields

Disclaimer: This test is for educational purposes only. Please consult your health care provider for detailed information about your risk for heart disease prevention, treatment options and a thorough heart and vascular exam.

Name*

First Name*

Last Name*

Email*

Phone*

Zip Code*

ZIP Code

Are you at risk for heart disease? Take our Heart Assessment to learn more.

Age*

51 and over 35-50 34 and under

FAMILY HISTORY: If you have parents or siblings who have had a heart attack, stroke or bypass surgery, at what age were they when it occured: *

Age 55 or before Age 56 or after None or Don't know

PERSONAL HISTORY: Have you ever had:*

A heart attack Angina, heart bypass surgery, angioplasty, stroke or blood vessel surgery None or don't know

Smoking*

Never Smoked Currently smoke Recently quit less than 1 year ago Quit smoking more than 2 years ago

Blood Pressure*

Elevated or high (either or both readings above 160/94 mmHg) Borderline (between 140/90 and 160/95 mmHg) Normal (below 140/90 mmHg) or don't know

How often do you exercise?*

5 or more times a week 3-4 times a week 1-2 or more times a week No regular exercise

(Aerobic activities such as brisk walking, jogging, bicycling, or rowing, etc. performed at a brisk pace for 30 minutes non-stop)

Body weight*

I'm within a normal weight for my height and age I'm about 30 lbs above my recommended weight I'm about 30-50 lbs above my recommended weight I'm over 50 lbs above my recommended weight

Do you have diabetes?*

No Yes, I try to help control it with my diet Yes, I control it with medications

Do you have a cardiologist?

Yes No

Total

Enter your save and resume password

Cancel

Confirm