Heart Assessment Tool

Gender?

Male Female

Are you taking medication to treat high blood pressure?

Yes No

Are you a smoker?

No, I never light up. I smoke occasionally. Yes, every day.

Do you exercise regularly?

Yes - I’m in the gym, out walking/running, or taking part in physical activities at least three times a week. I workout occasionally -- right after New Year’s Day and a couple times over the summer when it’s too nice to be inside. No – I’m not even sure where my sneakers are anymore.

Do you enjoy a balanced diet?

Yes – I regularly eat fruits and vegetables and I’m careful to avoid overindulging in foods that are likely to drive up my bad cholesterol. I eat fairly well, but I have my weaknesses – cheeseburgers, anything fried, you know, anything you can get at a good county fair. No – I only like it if it’s fried and salted.

Is there a history of heart disease in your family?

No. I’m not sure. Yes.