Cardiovascular Health Questionnaire

Cardiovascular Questionnaire

Cardiovascular health may be related to many other secondary health concerns. Proper assessment and a treatment plan are important to optimize one’s health.
This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to your Cardiovascular Health .  It is not a substitute for professional medical advice from your health care provider.

For each “Yes” answer, circle the Point Score in that section. Score the following with the numbers in brackets choosing the severity  that best suits you when indicated.

Add your points at the end and enter in the total score.

1.  ____ Do you have blood pressure that is higher than:

• 120/70? ( 30)
• 130/80? ( 40)
• 140/90? ( 50)
• 150/100? ( 100)

2.  ____ Do you have high cholesterol or triglyceride levels? (100)

3.  ____ Do you have a TC/HDL-Ratio higher than 3.8? ( 60)
4.  ____ Do you have blood sugar concerns ie diabetes or hypoglycemia ( feeling unwell after sweets or long periods between meals ) ? ( 50)
5.  ____ Do you carry extra weight around the abdominal area? ( 70)

6.  ____ Do you exercise less than:

• 3 times per week for 30 minutes each time? ( 50)
• 2 times per week for 30 minutes each time? ( 70)
• Once per week for 30 minutes? ( 90)
• I do not exercise? ( 100)

7.  ____ Rank your degree of stress, on a scale of 1/10 , 10 with the greatest amount :

• 1-4 ( 20)
• 5-6 ( 40)
• 7-8 ( 50)
• 9-10 ( 60)

8.  ____ I am able to share how I feel ( easily 10, moderately 30, not able to  50)

9.  ____ Do you eat fried foods more than once every 2 weeks? ( 80)

10. ____ Do you eat fruits and vegetables twice per day ? ( most of the time 10, 50% of the time 30, not often 50)

11.  ____ Do you eat sweets? ( not very often 10, moderately 30, very often 50)

12. ____ Do you feel your diet needs to be more heart healthy? ( 50)

13. ____ Do you have a family history of high blood pressure, high cholesterol, heart attack, stroke, heart disease, diabetes or obesity?  ( 100)

Total Score______
If you have a total score of more than 300 there is a probability that you are at risk for cardiovascular disease.

It is recommended to consult with your health care professional team.

To book an appointment.