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Cardiovascular Disease Risk Questionnaire
Please fill out the information below. All fields are mandatory
Step 1 of 2
Health Information
Gender
Age
Systolic Blood Pressure (mm Hg)
Diastolic Blood Pressure (mm Hg)
Total Cholesterol (mg/dL)
HDL Cholesterol (mg/dL)
LDL Cholesterol (mg/dL)
History of Diabetes?
*
Yes
No
Smoker?
*
Current
Former
Never
On Hypertension Treatment?
*
Yes
No
On a Statin?
*
Yes
No
On Aspirin Therapy
*
Yes
No
Continue to Step 2
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