Women and Heart Questionnaire

Women and Heart Questionnaire

The John Muir 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.

Questionnaire

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*
*
*
*
*
*
*
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 Yes
 No
*
 Yes
 No
*
 Yes, but not taking medication
 Yes, and taking medication
 No
*
 None regularly
 1 day weekly
 2 days weekly
 3 days weekly
 4 days weekly
 5 days weekly
 6 days weekly
 7 days weekly
*
 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
*
 Seldom or never
 Some meals
 Most meals
 Every meal
*
 None
 One to six
 Seven to 13
 14 to 20
 21 or more
*
 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
*
 Yes
 No
*
 Less than 130/85
 (130-139)/(85-89)
 140/90 or higher
 Don't know
*
 180 or below
 181-199
 200-239
 240 or higher
 Don't know
*
 Taking birth control pills
 Reached or passed menopause (naturally or early through surgery or other treatment)
 Taking estrogen, female hormones
 None apply
*
 Coping very well
 Coping fairly well
 Have trouble coping at times
 Often have trouble coping
 Feel unable to cope any more
*
 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

Have you thought about making lifestyle changes?

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

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 Haven't thought about changing
 Plan a change in next six months
 Plan to change this month
 Recently started doing this
 Do this regularly (last six months)
*
 Haven't thought about changing
 Plan a change in next six months
 Plan to change this month
 Recently started doing this
 Do this regularly (last six months)
*
 Haven't thought about changing
 Plan a change in next six months
 Plan to change this month
 Recently started doing this
 Do this regularly (last six months)
*
 Haven't thought about changing
 Plan a change in next six months
 Plan to change this month
 Recently started doing this
 Do this regularly (last six months)
*
 Haven't thought about changing
 Plan a change in next six months
 Plan to change this month
 Recently started doing this
 Do this regularly (last six months)
*
 Haven't thought about changing
 Plan a change in next six months
 Plan to change this month
 Recently started doing this
 Do this regularly (last six months)
 
 Quitting smoking
 Weight management
 Aerobics to music
 A walking group
 A jogging group
 A fitness evaluation
 Nutrition improvement
 Cholesterol reduction
 Blood pressure control
 Reducing coronary risk
 Cancer risk reduction
 Alcohol/drug awareness
 Healthy back program
 Medical self-care
 Stress management
 CPR training
 First aid
 Health evaluation
 Women's health issues
 Diabetes education
 Communication skills
 AIDS/preventing STDs
 Do not notify me of health promotion opportunities

* Asterisks indicate required fields