Heart Saver Questionnaire
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height & Weight
*
E-Mail
*
example@example.com
Have you ever had (Please check all that apply)
*
Diabetes
Heart Disease
Heart Attack
High Blood Pressure
Sleep Apnea
Use a C-PAP machine
Bleeding Disorders
Lung Disease
None of the above
Other illnesses:
Do have a family history of Heart disease?
*
YES
NO
If you answer YES, who in your family has a history and what is the history?
Are you currently experiencing chest pain or shortness of breath?
*
YES
NO
If you answered YES,
PLEASE STOP HERE AND SEEK MEDICAL ATTENTION.
Have you had a Cardiac Calcium Score, Coronary CT Angiogram or heart catheterization in the past?
*
YES
NO
If you answered YES, when (YEAR)?
Habits
How often do you exercise?
*
Never
1-2 days
3-4 days
5+ days
What is your typical alcohol consumption?
*
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
What is your typical caffeine consumption?
*
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
*
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Include other comments regarding your Medical History
Submit
Should be Empty: