Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Heart Disease *

You

Blood Relative

None

Stroke *

You

Blood Relative

None

High Blood Pressure *

You

Blood Relative

None

High Blood Cholesterol *

You

Blood Relative

None

Diabetes *

You

Blood Relative

None

Colon / Rectal Cancer *

You

Blood Relative

None

Skin Cancer *

You

Blood Relative

None

Stomach Cancer *

You

Blood Relative

None

Breast Cancer *

You

Blood Relative

None

Prostate Cancer *

You

Blood Relative

None

Uterine / Edometrial / Cervicale Cancer *

You

Blood Relative

None

Asthma *

You

Blood Relatives

None

Gout *

You

Blood Relative

None

Osteroporosis *

You

Blood Relative

None

Osteo / Rheumatoid Arthritis *

You

Blood Relative

None

Overweight *

You

Blood Relative

None

Alcoholism *

You

Blood Relative

None

Crohn's Disease *

You

Blood Relative

None

Diverticulitis *

You

Blood Relative

None

Ulcerative Colitis *

You

Blood Relative

None

Recurrent Bronchitis

You

Blood Relative

None

Anorexia Nervousa / Bulimia *

You

Blood Relative

None

General Eating Disorder *

You

Blood Relative

None

Amennoreha *

You

Blood Relative

None

Stress Disorder *

You

Blood Relative

None

Mental Illness *

You

Blood Relative

None

Depression *

You

Blood Relative

None

Multiple Sclerosis *

You

Blood Relative

None

Hepatitis *

You

Blood Relative

None

HIV +/ Aids *

You

Blood Relative

None

Have you stopped having periods because of menopause? *

YES

NO

Are you currently involved in hormone replacement therapy? *

YES

NO

Have you ever had a Bone Density Test performed? *

YES

NO

If no, are you interested in having a BDT performed?

YES

NO

Has you physician ever told you that you have heart trouble? *

YES

NO

Have you been aware of heart palpitations? *

YES

NO

In the last 3 months have you experienced any pain, pressure or discomfort in your chest? If so, describe the character of the discomfort (check all that apply). *

YES

NO

Sharp, fleeting, localized pain or “catch” *

YES

NO

Intensity changed if you took a deep breath or changed positions *

YES

NO

Dull pressure, ache, tightness, pain or burning *

YES

NO

Radiates to the jaw, arm, neck, shoulder or back *

YES

NO

Predictably brought on by exertion *

YES

NO

Has awakened you from sleep *

YES

NO

Predictably relieved by rest within 10 minutes *

YES

NO

Predictably relieved by nitroglycerine within 10 minutes *

YES

NO

Are troubled with dizziness or near fainting? *

YES

NO

Do you easily become short of breath? *

YES

NO

Do you wake during the night short of breath? *

YES

NO

Do you elevate your head to help you breathe at night? *

YES

NO

Do your ankles swell? *

YES

NO

Do you have leg cramps when walking? *

YES

NO

Has your physician ever told you that you have a heart murmur? *

YES

NO

Has your physician ever told you that you had an abnormal ECG indicating any pathology? *

YES

NO

Have any of your blood relatives died of heart disease before the age of 60 years? *

YES

NO

Have you ever had a heart attack or bypass surgery/angioplasty? *

YES

NO

Are you or have you ever been involved in a cardiac rehab program? *

YES

NO