Less than 35 yr 35-39 yr

40-48 yr 49-53 yr

54 yr and greater


2. Age (in years) Women?

Less than 42 yr 42-44 yr

45-54 yr 55-73

74 yr and greater


3. My family has a history of heart disease, heart attack, or High blood pressure... before the age of 55 yr.

Yes No


4. I have a personal history of heart disease, heart attack or High blood pressure....before the age of 55 yr.

Yes No


5. I rarely exercise or do anything physically demanding.

Yes No


6. I am more than 20 pounds over my ideal body weight.

Yes No


7. I am a smoker.

Yes No


8. I am a diabetic.

Yes No


9. Total Cholestrol Level

Less than 200 mg/dl 200 to 250 mg/dl

251 to 315 mg/dl More than 315 mg/dl


10. HDL Cholestrol Level

39mg/dl and higher 30-38 mg/dl

If under 30 mg/dl


11. Blood Pressure

My top blood pressure number is less than 140 mmHg My top blood pressure number is 140-170 mmHg

My top blood pressure number is greater than 170mmHg I am currently taking blood pressure medication