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Cardiac Risk Assessment
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First Name:
Last Name:
MI:
Email Address:
Phone Number:
Date of Birth:
Age:
Gender:
Male
Female
Race:
Caucasian
African American
Other
Heart disease:
No
Yes
If yes, are you currently being treated for this:
Hypertension:
No
Yes
If yes, are you currently being treated for this:
High cholesterol:
No
Yes
If yes, are you currently being treated for this:
Diabetes:
No
Yes
If yes, are you currently being treated for this:
Vascular disease:
No
Yes
If yes, are you currently being treated for this:
Smoking:
No
Yes
If a former smoker, when did you quit:
Do you exercise:
No
Yes
Do you ever experience chest pain or shortness of breath:
No
Yes
Does chest pain or shortness of breath occur with exercise:
No
Yes
Do you have a family history of heart disease:
No
Yes
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Cardiac Risk Assessment
Medical Questionnaire
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