Risk Assessment

1

Age?

2

Gender?

Male

Female

3

Have you had any of the following?* This field is required.Select all that apply

Heart attack or coronary bypass surgery

Stroke or transient ischemic attack (TIA)

Peripheral artery disease — reduced blood flow in arteries in your legs, arms or other areas

Angioplasty or stent placement — a procedure to open narrowed or clogged arteries by placing a small tube (stent) in an artery to keep it open and prevent it from narrowing

Any aneurysm — enlargement of the lower area of the major blood vessel (aorta) that supplies blood to the body

None of the above

I don't know

4

Have your parents, siblings or children had any of the following?* This field is required.Select all that apply

Heart attack or coronary bypass surgery

Stroke or transient ischemic attack (TIA)

Peripheral artery disease — reduced blood flow in arteries in your legs, arms or other areas

Angioplasty or stent placement — a procedure to open narrowed or clogged arteries by placing a small tube (stent) in an artery to keep it open and prevent it from narrowing

Any aneurysm — enlargement of the lower area of the major blood vessel (aorta) that supplies blood to the body

None of the above

I don't know

5

Do You Have High Blood Pressure Greater Than 120/70?* This field is required.

YESNO

6

Do you have Diabetes, Pre-Diabetes, Insulin Resistance or Metabolic Syndrome?* This field is required.

YESNO

7

Do you use any form of nicotine or vape?

YESNO

8

Do gums bleed when you brush or floss?

YESNO

9

Have you had any of the following?

CT Coronary Artery Calcium Score

Ultrasound of the Carotid Artery Wall

Intima Media (CIMT)

None of the above

Unknown

10

Were any of those test results abnormal?

Yes

No

11

Where should we send your risk results?

Email

12