Heart Disease Risk Assessment

The following questionnaire gives a sense of the likelihood of having or developing heart disease.

Are you over age 55?
Do you currently smoke? Yes No
Do you have an immediate family member (parent, sibling, or child) who has developed, or died from, heart disease before the age of 65? Yes No
Are you overweight? Yes No
In terms of your body type, do you carry your weight high in your body rather than low in your body (apple shape rather than pear shape body)? Yes No
Would you describe the amount of weekly exercise that you get as low (less than 30 minutes of physical activity on most days)? Yes No
Have you already experienced menopause? Yes No

Has a blood test in recent years shown that you have high cholesterol?

Yes No
Has a blood test in recent years shown that your  LDL is too high? Yes No
Has a blood test in recent years shown that your HDL is too low? Yes No

Has a blood test in recent years shown that you have high triglycerides?

Yes No
Is your blood pressure greater than 140/90 or higher? Yes No
Does your diet consist of high-fat foods? Yes No
Do you ever experience rapid fatigue, shortness of breath, or light-headedness from modest physical exertion, such as walking or climbing stairs? Yes No

In recent years, have you fainted?

Yes No

Have you ever experienced symptoms of angina (pain, heaviness, or discomfort in your chest – or arm or jaw pain, or pain around the shoulder blades), especially with exertion?

Yes No

If you previously smoked, has it been less than five years since you quit?

Yes No
Are you exposed to second-hand cigarette smoke? Yes No

Have you gone for years without regular medical check-ups?

Yes No
Do you have diabetes? Yes No
Have you ever had a stroke? Yes No
Have you ever had symptoms of a “temporary” or “mini” stroke (temporary weakness in an arm or leg, or difficulty speaking that is otherwise unexplained)? Yes No
Would describe the stress levels in your life as high? Yes No
Averaged, do you have the equivalent of more than one drink of alcohol per day? Yes No

The more often you answered “Yes” to the above questions, the greater your risk for developing or already having heart disease.  If you answered “Yes” to questions above, consider discussing heart disease with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.


>> See also the Coronary Artery Disease Risk Assessment in Aria's Health Information Library.