Assessment for Cardiovascular Event Risk
Name
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Best Number to reach you
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
1. What is your age and gender?
Male < 45 years old 0 POINTS
Female < 55 years old 0 POINTS
Male > 45 years old 4 POINTS
Female > 55 years old 4 POINTS
2. Do you have a family history of early cardiovascular disease, with a male relative affected before age 55 or a female relative affected before age 65?
No 0 POINTS
Yes 4 POINTS
3. What is your waist circumference?
Female: Less than 35 inches 0 POINTS
Male: Less than 40 inches 0 POINTS
Female: 35 inches or more 4 POINTS
Male: 40 inches or more 4 POINTS
4. What is your Body Mass Index (height-weight ratio)?
Underweight (18.5) 2 POINTS
Normal (18.5-24.9) 0 POINTS
Overweight (25-29.9) 3 POINTS
Obese (>= 30) 4 POINTS
5. What is your resting pulse rate?
Less than 60 beats per minute 0 POINTS
Less than 75 beats per minute 1 POINT
More than 75 beats per minute 2 POINTS
Don't know 2 POINTS
6. What is your blood pressure? (Select all that apply)
Less than 120/80 0 POINTS
Taking blood pressure medication 2 POINTS
120/80 to 139/89 3 POINTS
140/90 or higher 4 POINTS
Don't know 4 POINTS
7. What is your total cholesterol level? (Check all that apply)
Less than 160 mg/dL 0 POINTS
160-200 mg/dL 1 POINT
Taking cholesterol medication 2 POINTS
Greater than 200 mg/dL 3 POINTS
Don't know 3 POINTS
8. What is your HDL (good) cholesterol level?
If you're a woman: Less than 60 mg/dL 3 POINTS
If you're a man: Less than 50 mg/dL 3 POINTS
If you're a woman: 60 mg/dL or higher 0 POINTS
If you're a man: 50 mg/dL or higher 0 POINTS
Don't know 3 POINTS
9. What is your LDL (bad) cholesterol level?
Less than 70 mg/dL 0 POINTS
70-100 mg/dL 1 POINT
100-130 mg/dL 3 POINTS
More than 130 mg/dL 4 POINTS
Don't know 4 POINTS
10. Which of the following best describes your triglyceride level?
Less than 100 mg/dL 0 POINTS
100-150 mg/dL 1 POINT
More than 150 mg/dL 3 POINTS
Don't know 3 POINTS
11. Do you have diabetes or high blood sugar?
No 0 POINTS
Yes, I am prediabetic 3 POINTS
Yes, I am diabetic 4 POINTS
I have not had my blood sugars tested 4 POINTS
12. Do you have bleeding gums? (Check all that apply)
Never 0 POINTS
Yes, when I brush or floss 2 POINTS
I usually don't floss my teeth 2 POINTS
13. Which of the following best describes your sleep patterns?
I sleep soundly for 6-8 hours a night 0 POINTS
I sleep restlessly for 6-8 hours a night 2 POINTS
I sleep less than 6 hours or more than 9 hours 3 POINTS
14. Do you snore?
No 0 POINTS
Yes, occasionally 1 POINT
Yes, frequently and loudly 3 POINTS
Yes, and I have sleep apnea 4 POINTS
15. Do you have rheumatoid arthritis or any other inflammatory disease such as psoriasis or lupus?
No 0 POINTS
Yes 4 POINTS
16. Have you been checked for vitamin D deficiency?
My vitamin D level is between 50-60 0 POINTS
My vitamin D level is less than 30 3 POINTS
I do not know my vitamin D level 3 POINTS
17. Do you have a history of migraine headaches?
No 0 POINTS
Yes, with no migraine aura 2 POINTS
Yes, with a migraine aura 3 POINTS
18. How would you characterize your ability to cope with stress?
I'm usually pretty laid back 0 POINTS
I have healthy ways to cope with stress 1 POINT
Sometimes people say I seem stressed 2 POINTS
I feel stressed and anxious most of the time 4 POINTS
19. Do you spend 11 or more hours a day sitting?
No 0 POINTS
Yes 4 POINTS
20. How much exercise do you get?
At least 30 minutes, 5 to 7 days a week 0 POINTS
At least 30 minutes, 2 to 4 times per week 1 POINT
30 minutes, once a week or less 2 POINTS
I do not exercise 4 POINTS
21. Do you smoke?
No 0 POINTS
I used to smoke, but have quit for at least 5 years 1 POINT
I used to smoke, but quit less than 5 years ago 2 POINTS
I am exposed to secondhand smoke regularly 3 POINTS
I smoke or use smokeless tobacco products 4 POINTS
22. Do you drink regular or diet soft drinks?
Never 0 POINTS
Rarely drink soda (diet or regular) 1 POINT
Once a week (diet or regular) 2 POINTS
More than once a week 3 POINTS
23. Do you watch the amount of carbs in your diet?
I limit my simple carbohydrate intake 0 POINTS
I know to balance my carb/protein balance 1 POINT
I never watch my carbohydrates 2 POINTS
The majority of my diet consists of carbs 4 POINTS
24. (Women Only): During pregnancy, did you experience high blood pressure or gestational diabetes?
No 0 POINTS
Yes 4 POINTS
25. (Men Only): Do you have erectile dysfunction?
No 0 POINTS
Yes 4 POINTS
What Your Score Means:
If you scored
0 points
, congratulations! You are taking excellent care of yourself. Should you choose to enroll in the higher tier which includes the Baledoneen Method, this program can help you maintain and enhance your cardiovascular health.
If you scored
1 to 10 points
, you have relatively few cardiovascular risks. You will benefit from learning how to optimize your heart health with the easy action steps in this program.
If you scored
11 to 20 points
, you have definite risks for arterial disease. This program will alert you to what you should be doing right now to combat these health threats.
If you scored
20 to 39 points
, you are at moderately high risk for cardiovascular disease and would be categorized as a cardiac patient. In our cardiac program, you'll learn how to identify and overcome hidden medical problems that may be putting your heart health in jeopardy.
If you scored
40 points or higher
, you are at high risk for cardiovascular disease. To prevent a heart attack or stroke, we recommend getting a comprehensive cardiovascular evaluation to establish therapies and lifestyle changes that are most likely to help you ward off a heart attack or stroke.
Submit
Should be Empty: