Are you at risk for Heart Disease? Fill out the form below to find out. If you would like someone to contact you to discuss these results, please ensure that your personal details are correct, then complete the section below.
Name:
Email:
Phone:
1. What is your gender & age? Select... Male <50 Male 50+ Female <50 Female 50+
2. Do you have any of the following conditions in your family history? Select... Blocked Ateries Heart Attack Stroke None of these
3. Is your HDL (Good Cholesterol) above 45? No Yes I don't know
4. Is your LDL (Bad Cholesterol) below 100? No Yes I don't know
5. Have you ever been diagnosed with high blood pressure? Yes No I don't know
6. Have you ever used blood pressure medication? Yes No
7. Have you smoked in the past 3 years? Yes No
8. Do you have Diabetes? Yes No
9. Please enter your height feet inches
10. Please enter your weight lbs
