Cardiovascular Risk Assessment Questionnaire

Thank you for your interest in participating in the Mercy Cardiac Disease Prevention Clinic! This important step will help identify risk factors that can lead to cardiovascular disease, especially heart attack and stroke. All recommendations will be based on the best current scientific evidence. Our goal is to provide you with an evaluation of risk factors that can cause serious medical events and provide a roadmap to beneficial habits and a path toward healthy living.

First, we need to find out a few things about you…







Briefly, describe your goals. What would you like to get out of today’s visit?

General information:

* = required entry

Gender:*




Race/Ethnicity:*





Physical activity

How many minutes of exercise do you get in a typical week?






Nutrition

How many times a week do you eat:


Which fats do you use in cooking most often?





What types of drinks do you prefer? (check all that apply)







Do you add salt during cooking and/or at the table?




How often do you compare products at the store and choose lower-sodium options?





Weight management

Blood pressure management

Are you taking medications for hypertension(High blood pressure)?*



Recent blood pressure range:






Do you have Chronic Kidney Disease?




Diabetes

Do you have diabetes?*




Do you have a history of coronary, cerebral or other vascular disease?



Do you have a history of Congestive Heart Failure?



Cholesterol management

Enter values for: (if unknown, leave entry blank)

Other risk factors

Have you ever had a coronary calcium score?




Enter the coronary calcium score:






Have you ever had hsCRP measurement?





Check all of the following that are true:
















Tobacco

Are you a current smoker?*



Did you smoke previously?




Do you live with someone who smokes?



Aspirin use

Do you use aspirin regularly?



Any questions you’d like to discuss with your provider?

Type any questions: