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…
Name: Date of birth:
Briefly, describe your goals. What would you like to get out of today’s visit?
What is your age? *
Gender:*
Race/Ethnicity:*
How many minutes of exercise do you get in a typical week?
How many times a week do you eat:
Beef or pork
Chicken or turkey
Fish or shellfish
Plant-based protein (tofu/tempeh/soy, beans, lentils)
Which fats do you use in cooking most often?
How many total servings of fruit do you consume each day?
How many total servings of vegetables or legumes (beans, peas, lentils) do you consume each day?
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?
How many times a week do you eat out (sit-down, take-out, fast-food restaurant)?
Enter weight:
Enter height (inches):
Waist circumference (inches):
Are you taking medications for hypertension(High blood pressure)?*
Recent blood pressure range:
Enter recent systolic blood pressure (the top number of blood pressure reading):*
Do you have Chronic Kidney Disease?
Do you have diabetes?*
Enter hemoglobin A1C (HgA1C) value, if known:
Enter Fasting Blood Sugar value, if known:
Do you have a history of coronary, cerebral or other vascular disease?
Do you have a history of Congestive Heart Failure?
Enter values for: (if unknown, leave entry blank)
Total cholesterol:*
LDL-cholesterol:*
HDL-cholesterol:*
Triglycerides:
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:
Are you a current smoker?*
Did you smoke previously?
Total years smoking:
Average packs per day:
Years since quitting:
Do you live with someone who smokes?
Do you use aspirin regularly?
Type any questions: