Please check the box "Yes" or "No" in response to each of the questions below
See below for scoring instructions

 
1.  What is your age?    Years             What is your gender?   
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 2.  Has anyone in your immediate family had heart disease or a heart attack before age 65?   Yes No
 3.  Do you have high blood pressure (130/80 or above) or are you on blood pressure
      medication? 		Yes No
 4.  Have you been told that you have high cholesterol or are you on cholesterol lowering       
      medication?		 Yes No
 5.  Have you been told that you have elevated blood sugar or Diabetes? Yes No
 6.  Do you currently use tobacco or have you quit within the last five years? Yes No
 7.  Are you 10 pounds or more overweight? Yes No
 8.  Do you commonly experience difficulty sleeping? Yes No
 9.  Do you commonly feel that you are overstressed? Yes No
 10.  Do you use relaxation techniques in your normal routine? Yes No
 11.  Do you regularly exercise three to five times weekly for at least 30 minutes? Yes No
 12.  Have you commonly avoided both red meat and fatty foods for the last year? Yes No
 13.  Do you have a fulfilling intimate relationship with a significant other? Yes No
 14.  Do you perceive that you receive good social support from family and friends? Yes No
 15.  Is it your perception that when growing up you were cared for and loved by your parents? Yes No
 16.  Do you laugh often and routinely experience humorous moments? Yes No
 17.  Do you believe you are in good health? Yes No
 18.  Do you regularly attend church, synagogue or temple? Yes No


SCORING INSTRUCTIONS:

Thank you for participating in this assessment of your heart health.  Please take the total number of ORANGE responses above and write the number in the box below.  Then, add up the BLUE responses and place them in the space below.

Please insert your score here:

Total Orange      Total Blue     


If your score is 8 or greater in the ORANGE area you may have an elevated risk for Cardiovascular Disease.  Preliminary indications suggest that approximately 70% of participants scoring 9 or above display symptoms of Heart Disease, including an elevated C-Reactive Protein level.  The American Heart Association has recommended that individuals with moderate or elevated risk for Heart Disease be screened with the C-Reactive Protein blood test.  For a limited time, Glendale Adventist Medical Center's Heart and Vascular Institute is providing a free Cardiovascular Screening that includes the C-Reactive Protein blood test for individuals demonstrating elevated risk for Cardiovascular Disease.  The Heart Disease Risk Assessment includes:

If you would like to be contacted about the date for GAMC's next free Cardiovascular Risk-Screening event,
please type your name and phone number in the spaces below.

Name 
Home Phone 
2nd Phone  


For more information, please call:

For English - (818) 409-8549
For Spanish - (818) 409-8549
For Armenian - (818) 409-8538

Please press the submit button below to enter your results

Major funding provided by the UniHealth Foundation


Glendale Adventist Medical Center
1509 Wilson Terrace
Glendale, CA  91206
(818) 409-8245

© 2003-2005 - Glendale Adventist Medical Center.  All rights reserved.