Women and Heart Questionnaire

Did your parent, brother, or sister ever have coronary heart disease, a heart attack, or coronary surgery (before age 55 in men, before age 65 in women)?

Is there a history of high blood cholesterol in your family (father, mother, sister, brother)?

Has a doctor informed you that you currently have diabetes (high blood sugar)?

Has a doctor informed you that you had a heart attack or you currently have coronary heart disease, angina, or congestive heart failure?

Has a doctor informed you that you have had a stroke or that you currently have restricted blood flow to your head or legs?

How many days per week do you engage in aerobic exercise of at least 20 to 30 minutes in duration (fitness walking, cycling, jogging, gardening, aerobic dance, or active sports)?

Intake Indicate the kinds of foods you usually eat. High saturated fat examples: hamburgers, hot dogs, bologna, sour cream, cheese, whole milk, eggs, butter, cake, pastry, ice cream, chocolate, many fast foods. Low saturated fat examples: lean meats, skinless poultry, fish, skim milk, low-fat dairy, fruit, gelatin desserts, vegetables, pasta

How often do you add salt to your food or eat salty foods (chips, pickles, soy sauce)?

How many alcoholic drinks do you usually have per week? One drink is 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor.

Indicate your current status.

Are you exposed regularly to secondhand smoke (other people's smoke) at home or work?

Indicate your usual blood pressure

Indicate your usual blood cholesterol level.

How well do you feel you are coping with your current stress load?

During the past four weeks, have you been a happy person?

Name
Address
City
State
ZIP
eMail
Phone
Date of Birth (for ID purposes ONLY)
Age
Height
Weight
Family Heart History Did your parent, brother, or sister ever have coronary heart disease, a heart attack, or coronary surgery (before age 55 in men, before age 65 in women)? Yes No Family Cholesterol History Is there a history of high blood cholesterol in your family (father, mother, sister, brother)? Yes No Diabetes Has a doctor informed you that you currently have diabetes (high blood sugar)? Yes, but not taking medication Yes, and taking medication No Coronary Heart Disease Has a doctor informed you that you had a heart attack or you currently have coronary heart disease, angina, or congestive heart failure? Yes, but not taking medication Yes, and taking medication No Stroke Has a doctor informed you that you have had a stroke or that you currently have restricted blood flow to your head or legs? Yes, but not taking medication Yes, and taking medication No Exercise How many days per week do you engage in aerobic exercise of at least 20 to 30 minutes in duration (fitness walking, cycling, jogging, gardening, aerobic dance, or active sports)? None regularly 1 day weekly 2 days weekly 3 days weekly 4 days weekly 5 days weekly 6 days weekly 7 days weekly Saturated Fat Intake Indicate the kinds of foods you usually eat. High saturated fat examples: hamburgers, hot dogs, bologna, sour cream, cheese, whole milk, eggs, butter, cake, pastry, ice cream, chocolate, many fast foods. Low saturated fat examples: lean meats, skinless poultry, fish, skim milk, low-fat dairy, fruit, gelatin desserts, vegetables, pasta Nearly always eat the high saturated fat foods Eat mostly the high saturated fat foods Eat both about the same Eat mostly low saturated fat foods Eat only low saturated fat foods Salt How often do you add salt to your food or eat salty foods (chips, pickles, soy sauce)? Seldom or never Some meals Most meals Every meal Number of Drinks How many alcoholic drinks do you usually have per week? One drink is 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor. None One to six Seven to 13 14 to 20 21 or more Smoking Status Indicate your current status. Have never smoked Quit smoking, two or more years ago Quit smoking, less than two years ago Smoke pipe or cigar Currently smoke less than 10 cigarettes daily Currently smoke 10 or more cigarettes daily Secondhand Smoke Are you exposed regularly to secondhand smoke (other people's smoke) at home or work? Yes No Blood Pressure Indicate your usual blood pressure Less than 130/85 (130-139)/(85-89) 140/90 or higher Don't know Cholesterol Indicate your usual blood cholesterol level. 180 or below 181-199 200-239 240 or higher Don't know Other Factors Mark any that apply Taking birth control pills Reached or passed menopause (naturally or early through surgery or other treatment) Taking estrogen, female hormones Coping Status How well do you feel you are coping with your current stress load? Coping very well Coping fairly well Have trouble coping at times Often have trouble coping Feel unable to cope any more Happiness During the past four weeks, have you been a happy person? All the time Most of the time A good bit of the time Some of the time A little of the time None of the time Readiness to change Have you thought about making lifestyle changes? Indicate how ready you are to make changes in your lifestyle in the following areas: Be physically active most days Live smoke- and tobacco-free Achieve/maintain a healthy weight Handle stress well Drink alcohol moderately if at all Live an overall healthy lifestyle

Have you thought about making lifestyle changes?

Indicate how ready you are to make changes in your lifestyle in the following areas:

Be physically active most days

Live smoke- and tobacco-free

Achieve/maintain a healthy weight

Handle stress well

Drink alcohol moderately if at all

Live an overall healthy lifestyle

2. Weight management

3. Aerobics to music

6. A fitness evaluation

7. Nutrition improvement

8. Cholesterol reduction

9. Blood pressure control

10. Reducing coronary risk

11. Cancer risk reduction

12. Alcohol/drug awareness

13. Healthy back program

14. Medical self-care

15. Stress management

18. Health evaluation

19. Women's health issues

20. Diabetes education

21. Communication skills

22. AIDS/preventing STDs

23. Do not notify me of health promotion opportunities


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