Your gender? Male Female Are you older than 45? Yes No Are you older than 55? Yes No Were your parents or a sibling diagnosed with heart disease before they were 55? Yes No Were your parents or a sibling diagnosed with heart disease before they were 65? Yes No Is your total blood cholesterol level higher than 200 milligrams per deciliter (mg/dL)? Yes No Not Sure Have you been told you have high blood pressure? Yes No Do you have diabetes (either type 1 or type 2)? Yes No Do you smoke tobacco? Yes No Do you lead a sedentary life? Yes No Are you interested in being contacted by the Southcoast Heart Center? Yes No Email* Phone*Zip Code* ZIP / Postal Code This assessment is not intended to replace the evaluation of a healthcare professional.