Name

Date of Birth

Age

Sex

Best Contact Phone Number

Email

Do you want these results to go to your primary care provider? Do you want these results to go to your primary care provider? YES NO

Family/Primary Care Physician Name

Family/Primary Care Physician Phone Number

Work you like to be referred to Preventative Cardiology if your results are positive? Work you like to be referred to Preventative Cardiology if your results are positive? YES NO

Has an immediate family member(s) (parent, sibling) had a heart attack, a stroke, or was diagnosed with heart disease before the age of 60? Has an immediate family member(s) (parent, sibling) had a heart attack, a stroke, or was diagnosed with heart disease before the age of 60? YES NO UNSURE

Have you been told you have high blood pressure? Have you been told you have high blood pressure? YES NO UNSURE

Have you been told you have high cholesterol? Have you been told you have high cholesterol? YES NO UNSURE

Have you smoked for any amount of time? Have you smoked for any amount of time? YES NO UNSURE

Are you overweight? Are you overweight? YES NO UNSURE

Do you have diabetes? Do you have diabetes? YES NO UNSURE