patientadvantage.com RTD AHA Survey

Your Name *

First Name Last Name
Employee Number *
A unique code provided by your employer.
Email Address *
Zip Code *
Gender *
Age *
Ethnicity *
Do you have diabetes (either Type 1 or Type 2) *

Yes No
Have you ever been diagnosed by a health care provider as having any of these conditions? (Select all that apply) *

Heart attack Heart failure Stroke/TIA Vascular Disease Congenital heart defects Coronary heart disease/chest pain NONE OF THE ABOVE

Exercise
Different intensities and types of activity provide different benefits. Generally, if you are able to talk while performing a physical activity, it’s moderately intense. But if you’re breathing hard and finding it hard to hold a conversation, the activity is vigorously intense. Vigorously intense activity burns more calories per unit of time.

Examples of Moderate Activity
• Walking briskly (3 miles per hour or faster but not race-walking)
• Water aerobics
• Bicycling slower than 10 miles per hour
• Tennis (doubles)
• Ballroom dancing
• General gardening

Examples of Vigorous Activity
• Race-walking, jogging, or running
• Swimming laps
• Tennis (singles)
• Aerobic dancing
• Bicycling 10 miles an hour or faster
• Jumping rope
• Heavy gardening (continuous digging or hoeing, with heart rate increases)
• Hiking uphill or with a heavy backpack

Note: This table provides several examples of activities classified as moderate or vigorous. It does not list all possible activities. Instead, the examples are meant to help you make choices.
How many hours of MODERATE physical activity do you get each week? (Walking, gardening, etc.) *
How many hours of VIGOROUS physical activity do you get each week? (Running, swimming, etc.) *

Vegetables
Any vegetable or 100% vegetable juice counts as a member of the vegetable group. Vegetables may be raw or cooked; fresh, frozen, canned, or dried/dehydrated; and whole, cut up, or mashed.

In general, 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy greens, can be considered a 1-cup serving.

A 1-cup serving of vegetables is the same as:
- 1 large bell pepper
- 1 medium potato
- 2 large celery stalks
- 1 cup cooked greens or 2 cups raw greens (spinach, collards, mustard greens, turnip greens)
- 2 cups lettuce
- 12 baby carrots or 2 medium carrots
- 1 large sweet potato
- 1 large ear of corn
- 10 broccoli florets
Some commonly eaten vegetables include:
- Dark green vegetables (all fresh, frozen, and canned dark green vegetables, cooked or raw)
- Examples: broccoli, spinach; romaine; collard, turnip, and mustard greens
- Orange vegetables (all fresh, frozen, and canned orange and deep yellow vegetables, cooked or raw)
- Examples: carrots, sweet potatoes, winter squash, and pumpkin
- Legumes (all cooked dry beans and peas and all soybean products)
- Examples: pinto beans, kidney beans, lentils, chickpeas, tofu
- Starchy vegetables (all fresh, frozen, and canned starchy vegetables)
- Examples: white potatoes, corn, green peas
- Other vegetables (all fresh, frozen, and canned other vegetables, cooked or raw)
- Examples: tomatoes, tomato juice, lettuce, green beans, onions
How many cups of vegetables do you eat in an average day? *
cups

Fruits
Fruits include fresh, frozen, canned, and dried fruits and fruit juices.

A 1-cup serving of fruit is the same as:
- 1 large orange
- 1 small apple
- 1 medium pear
- 1 large banana
- 1 medium grapefruit
- 1 small watermelon wedge
- 1 large cantaloupe wedge
- 2 large or 3 medium plums
- 8 large strawberries
- 32 grapes
- 1/2 cup raisins
How many cups of fruit do you eat in an average day? *
cups

Fish
A serving of fish is 3.5 ounces, approximately the same size as a deck of cards
How many servings of fish do you eat in an average week? *
servings

Whole Grains
Whole grains include all whole-grain products and ingredients.

For example, one serving is an ounce, which equals:
- 1 slice whole-wheat or rye bread (whole-grain ingredient listed first)
- 1 cup 100% whole-grain cold cereal
- 1/2 cup 100% whole-grain hot cereal (whole oats or oatmeal)
- 1/2 cup cooked whole-wheat pasta, brown rice, or other grain like barley (about half the size of a baseball)
- 3 cups popped popcorn
Tip: Foods labeled "multigrain", "stone-ground", "100% wheat", "cracked wheat", "seven-grain", or "bran" are usually not whole-grain products.
How many servings of whole grains do you eat in an average day? *
servings

Sugar and Processed Foods

Added sugars are the sugars and syrups added to foods and beverages in processing or preparation (e.g., sweetened cereals, crackers, pies and other pastries, cakes, cookies), not the naturally occurring sugars in fruits or milk.

Sugar-Sweetened Beverages	Caloriers from Sugars
1 can (12 ounces) non-diet soda	150 calories
1 cup (8 ounces) fruit drink like lemonade	100 calories

Note: 1 teaspoon of sugar = 4 grams = 16 calories.

The calories shown above are estimates. The number of calories from sugars in the beverages you consume may be different.

How many 12 ounce beverages with added sugars do you drink every week? *
12 oz beverages
Select any of the following statements that apply to you: *

I avoid eating pre-packaged and processed foods I rarely eat out, but when I do, I seek out lower sodium options I avoid salt when I'm cooking at home NONE OF THE ABOVE

Vital Metrics
Three vital metrics can help you understand your heart health. Your doctor can help you get the details on each.

You're going to be asked about your blood pressure, blood cholesterol, and blood sugar.

If you don't have some information, you can select "I DON'T KNOW" to skip that question.
Systolic blood pressure is the first or top number of your blood pressure and measures pressure during heartbeats. For example, if your blood pressure is 117/76, then your systolic blood pressure is 117.
Your SYSTOLIC blood pressure (in mmHg): *
mmHg
Diastolic blood pressure is the second or bottom number of your blood pressure and measures pressure between heartbeats. For example, if your blood pressure is 117/76, then your diastolic blood pressure is 76.
Your DIASTOLIC blood pressure (in mmHg): *
mmHg
Please select if any of the following apply:

I DON'T KNOW these numbers I take medication to lower my blood pressure
Total blood cholesterol is the most common measurement of blood cholesterol.

It's the number you receive as a test result. Cholesterol is measured in milligrams per deciliter of blood (mg/dL).
Your BLOOD CHOLESTEROL (in mg/dL): *
mg/dL
Please select if any of the following apply:

I DON'T KNOW this number I take medication to lower my blood cholesterol
Fasting blood sugar measures a type of sugar, called glucose, in your blood after you have not eaten for at least 8 to 12 hours.

It often is the first test done to check for diabetes.
Your BLOOD SUGAR fasting (in mg/dL): *
mg/dL
Please select if any of the following apply:

I DON'T KNOW this number I take medication to lower my blood sugar
The hemoglobin A1C test (HbA1C) reflects the average of a person’s blood sugar levels over the past 2 to 3 months and is reported as a percentage. No fasting is required for this test.

The A1C test can be used to diagnose prediabetes and type 2 diabetes and can also be used for diabetes management.
A1c (in percent): *
%
Please select if any of the following apply:

I DON'T KNOW this number I take medication to lower my blood sugar
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Exercise

Vegetables

Fruits

Fish

Whole Grains

Sugar and Processed Foods

Vital Metrics