LIFESTYLE QUESTIONNAIRE
1. Do you have a family history of early coronary artery disease? Example: a mother or sister
younger than 60 years old, and/or, a father or brother younger than 50 years old when he/she
had their first heart attack symptoms?
a. No
b. Yes
2. Do you have high blood pressure (BP >140/90)?
a. No
b. Yes
c. Do not know
3. Do you have diabetes or elevated blood sugar?
a. No
b. Yes
4. Are you physically active?
a. Yes, I accumulate approximately 30 minutes of moderate aerobic activity per day.
b. I exercise only occasionally, 30 minutes of aerobic activity one to two days per week
c. I rarely engage in moderate aerobic cal activity.
5. Which of the following best describes your cholesterol?
a. <200mg/dL
b. 201-239 mg/dL
c. >240mg/dL
d. Do not know
6. Which of the following best describes your triglyceride level?
a. 150-199 mg/dL
b. 200-250 mg/dL
c. >250 mg/dL
d. Do not know
7. Do you smoke?
a. No
b. Yes
c. Smoked previously, stopped within the last year.
d. Smoked previously, stopped 5 years ago.
e. Smoked previously, stopped within 10 years or more ago.
8. Describe your level of stress:
a. I take life in stride and don’t carry much stress.
b. I find work, home life and finance occasionally stressful.
c. I seem to be stressed constantly, even by minor things.
Please let us know if any of the answers to these lifestyle questions are a concern for
you. Vessel Health is here to help you make lifestyle changes that can improve your
quality of life and overall health.