Heart Disease Risk Assessment

Your Personal Risk Profile for Cardiovascular Disease
Self-Assessment Quiz

To complete our risk profile, enter the number that corresponds with the answer
you choose on the line provided.

Name*
First Last
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
How old are you?*
<40 = 0 40-44 = 1 45-49 = 2 50-54 = 4 55-59 = 6 =/>60 = 8
What is your gender?*
*Postmenopausal women taking hormone therapy should consider themselves premenopausal for the purpose of this quiz.
Male = 2 Postmenopausal female = 2 *Premenopausal female = 0
Are you a smoker?*
I currently smoke = 2 I stopped smoking 1-5 years ago = 1 I stopped smoking more than 5 years ago = 0 I am a nonsmoker = 0 I live with a smoker = 1
Are you overweight?*
BMI =< 25 = 0 BMI 26-29 = 2 BMI 30-31 = 4 BMI => 32 = 6
Do you have a family history of heart disease?*
No family history of heart disease = 0 One first-degree relative with heart disease = 4 Two first-degree relatives with heart disease = 6 No knowledge of family history = 3
Do you currently have coronary heart disease?*
Yes = 6 No = 0
Do you have coronary ear creases* on both ears?*
*A coronary ear crease is a 45-degree crease that slants upward in the direction from your neck to your eyebrow.
Yes = 1 No = 0
Do you have vertex male-pattern baldness (bald top of head, hair on sides)?*
Yes = 1 No = 0
Do you have yellow-white rings circling your pupils, in the colored part of your eye (called arcus senillis)?*
Yes = 1 No = 0
Has it been your habit to eat fish at least three times a week?*
Yes = 2 No = 0
Are you of…*
Asian descent? Yes = 6 Native American descent? Yes = 3 Mexican-American descent? Yes = 3 Native Hawaiian or Pacific Islander descent? Yes = 3 None of the above = 0
How often do you eat red meat?*
Daily = 2 3-4 times a week = 1 1 time a week/rarely/never = 0

3. How often do you exercise?*

6 or 7 times a week for at least 2 years = -2	4 or 5 times a week for at least 2 years = -1	3 times a week for at least 2 years = 0	Less than 3 times a week for at least 2 years = 1	No routine exercise = 3

Are you in a high economic bracket for your geographic location?*
Yes = -1 No = 0
Do you intentionally include fiber in your diet on a daily basis?*
Yes = -1 No = 0
Are you divorced (and not remarried)?*
Yes = 1 No = 0
Have you regularly worked late night shifts for 20 years or more?*
Yes = 1 No = 0
Do you have a quick temper?*
Yes = 1 No = 0
Do you consume black or green tea on a daily basis?*
Yes = -1 No = 0
Do you have kidney disease?*
Yes = 2 No = 0
Do you have chronic oral gum disease?*
Yes = 1 No = 0
Do you have more than two colds or infections per year?*
Yes = 1 No = 0
Do you have blood type A?*
Yes = 1 No = 0 Don’t know = 0
Do you have blood type O?*
Yes = -1 No = 0 Don’t know = 0
Does your mother, father, or any of your siblings have diabetes?*
Yes = 2 No = 0
Are you concerned that you may have an undiscovered metabolic risk for heart attack?*
Yes = 2 No = 0
Do you have a history of high blood pressure?*
Yes – Chronically and not well-controlled = 4 Yes – Chronically but well-controlled = 2 Yes – But only occasionally noticed = 1 No = 0
Have you had your blood cholesterol tested?*
Yes = 0 No = 2
Do you have a history of high blood cholesterol?*
Yes = 3 No = 0 Don’t know = 0
Do you have a history of low HDL cholesterol?*
Yes = 3 No = 0 Don’t know = 0
Adapted from Before the Heart Attacks (2003) by Robert Superko, MD, FACC, FAHA, co-founder of the Berkeley Heartlab.
Name
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Heart Disease Risk Assessment

Your Personal Risk Profile for Cardiovascular Disease
Self-Assessment Quiz

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Heart Disease Risk Assessment

Your Personal Risk Profile for Cardiovascular DiseaseSelf-Assessment Quiz

Your Personal Risk Profile for Cardiovascular Disease
Self-Assessment Quiz