NE Patient Heart Saver Questionnaire

Heart Saver Questionnaire
Name *

First Name Last Name
Gender *
Birth Date *

Month Day 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
Should be Empty:

Heart Saver Questionnaire