AFCA GENETIC SCREENING
Cardiovascular Qualifying Questionnaire
Name
*
First Name
Last Name
Address
*
Address
Street Address Line 2
City/State/Zip
State / Province
Postal / Zip Code
Home Phone
Phone number
Cell Phone
*
Phone number
Email
*
example@example.com
Have you or your family had any of the following (Check all that apply)
*
Personal history of Cardiomyopathy
Family history of Cardiomyopathy
Episodes of chest pain
Dizziness
Fatigue
Abnormal heart rate
Shortness of breath
Swelling of extremeties and weight gain
Have you or your family had any of the following (Please check all that apply):
Elevated Cholesterol
LDL-C level
Total cholesterol level
Coronary Heart Disease (CHD)
Acutemyocardialinfarction (AMI)
Myocardial infarction (silent MI)
Atherosclerotic cardiovascular disease o Unstable angina
Coronary revascularization procedure (PCI or CABG)
Vascular Disease
Cerebral
Peripheral
Tendon Xanthoma(s)
Corneal Arcus
Other
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Are you taking any type of cardiovascular medications such as: Beta-Blockers, Antiarrhythmic, or Statins
*
Yes
No
Do you cough while laying down?
Please Select
Yes
No
Have you ever experienced bloating to the abdomen due to fluid buildup?
Please Select
Yes
No
Have you experienced any form of chest discomfort or pressure?
Please Select
Yes
No
Description of chest discomfort or pressure:
Do you have long-term high blood pressure?
Please Select
Yes
No
Have you ever suffered from obesity, thyroid disease or diabetes?
Please Select
Yes
No
Do you have a heart valve?
Please Select
Yes
No
If so, have you experienced any issues?
Please Select
Yes
No
Have you ever had any issues with pregnancy?
Please Select
Yes
No
Have you excessively used alcohol over 5 years?
Please Select
Yes
No
Front of ID
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Back of ID
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Front of Insurance Card
*
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Back of Insurance Card
*
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Don't be a statistic. Learn your genetic risk factors before it's too late.
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