Stroke Risk Assessment

1

Your Name

First Name

Last Name

2

Email

name@example.com

3

Phone Number

4

Do you have high blood pressure?

Yes

No

I'm not sure

5

How often do you smoke or vape tobacco or cannabis products?

Rarely or never

Occasionally

Regularly

6

Do you have diabetes?

Yes

No

Borderline

I'm not sure.

7

How often do you exercise?

Regularly

Sometimes

Rarely or never

8

How is your weight?

I am average weight.

I am slightly overweight.

I am overweight

9

Do you have high cholesterol?

Yes

No

I'm not sure.

10

Do you have AFib?

Yes

No

I don't know.

11

Have you ever had a blood clot or clotting problems before?

Yes

No

12

How often do you use alcohol or non-prescribed/illegal drugs?

Rarely or never

Sometimes

Regularly

13

Do you take birth control pills?

Yes

I recently stopped.

No

14

Do you have migraines?

Yes

No

15

Have you ever had a heart attack, stroke, or TIA (transient ischemic attack)?

Yes, one or more times

No

I don't know.

16

Is there a history of stroke in your family?

Yes

No

I don't know.

17

Are there any health issues you are concerned about?

18

Can we contact you?We are happy to help you make an appointment or answer any questions you have.

Yes, please contact me.

No, please do not contact me.

19

Please verify that you are human.* This field is required.

20

Your Risk Assessment ScoreWrite down your score. Click NEXT to submit your form and see what your score means.

Remember to write down your score!

21

Thank you for taking an important step in protecting yourself from stroke.

Your risk score is {calculation}.

When you press the SUBMIT button below, you will be taken to the Kaweah Health website where you can see what your score means, find tips on reducing your stroke risk, and get information on making an appointment with a doctor.

Your score is private and is only visible here, so be sure to make a note of it before clicking SUBMIT.