Women's Heart Questionaire form

The John Muir Health Women's Heart Program is designed to help women of any age identify their risk of heart disease. Kindly complete and submit the questionnaire below. Once we've reviewed your questionnaire, we'll mail a summary report to you within ten business days.

Full Name*

Address*

City*

State*

Zip Code*

Email*

Phone*

Date of Birth (for ID purposes only)*

Height: Feet*

Height: Inches*

Weight (Pounds)*

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

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

Yes

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 without medication

Yes and taking medication

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

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

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

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

Indicate your current status. *

Have never smoked

Quit smoking, two or more years agoQuit 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

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

Yes

Indicate your usual blood pressure *

Less than 130/85

(130-139)/(85-89)

140/90 or higher

Don't know

Indicate your usual blood cholesterol level. *

180 or below

181-199

200-239

240 or higher

Don't know

Mark any that apply *

Taking birth control pills

Reached or passed menopause (naturally or early through surgery or other treatment)

Taking estrogen, female hormones

None apply

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

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 coping

A little of the time

None of the time