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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
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Age
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Systolic Blood Pressure (mm Hg)
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Diastolic Blood Pressure (mm Hg)
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Total Cholesterol (mg/dL)
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HDL Cholesterol (mg/dL)
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LDL Cholesterol (mg/dL)
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History of Diabetes?
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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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