1. Have you been diagnosed with any of these conditions? (check all that apply):

Previous heart attack
Diabetes. (Fasting blood sugar of 126 or higher?)
High Blood Pressure. (BP over 140/90)
High Cholesterol. (Total cholesterol 200 mg or higher?
       HDL [good] cholesterol less than 40 mg/dL?)
Angina
Metabolic syndrome.*

Metabolic syndrome involves 3 or more of the following measurements:

1. A waist measurement greater than 35 inches for women
2. Triglycerides of 150 or more.
3. An HDL level of less than 50.
4. Blood pressure of 130.85 or more (either number counts)
5. Blood sugar of 110 or more.

2. Do you have a father or a brother who had a heart attack or stroke before age 55 or a mother or sister who had a heart attack before age 65?:

Yes
No

3. Do you now smoke or have you stopped smoking within six months?:

Yes
No

4. Based on your BMI (Body Mass Index) are you…

Underweight (BMI below 18.5)
Normal weight (BMI between 18.5 and 24.9)
Overweight (BMI between 25.0 and 29.9)
Obese (BMI 30.0 and above)

5. Is your waist circumference measurement more than 35 inches?
       Note: Measure your waist while standing, just after you breathe out,
       and place the tape around your waist just above the hip bones.

Yes
No

6. Is your waist circumference measurement more than 40 inches?
       Note: Measure your waist while standing, just after you breathe out,
       and place the tape around your waist just above the hip bones.

Yes
No

7. Do you regularly eat a diet that include all following?

• Low saturated fat
• Low cholesterol
• Low salt
• Low – moderate calorie
• Five fruits and vegetables daily
• Whole grains daily

Yes
No

8. Do you get less than a total of 30 minutes activity on most days?

Yes
No

9. Do you have symptoms of sleep disturbances, such as sleep apnea?
       (heavy snoring, gasping or choking during sleep along with extreme daytime sleepiness)

Yes
No

10. Do you have problems with stress and / or depression?

Yes
No

11. Do you drink more than one alcoholic drink per day?

Yes
No

12. Have you had the following recommended tests on schedule?
       (check all that apply to you)

I have not had a BP check within the past two years
I have not had a Lipoprotein Profile within the past five years.(This is a blood test that measures both total cholesterol and triglyceride levels.)
I have not had a Fasting Plasma Glucose test within three years. (You should be tested younger and more often if diagnosed with diabetes.)
I have not had a Body Mass Index (BMI) measurement within the past two years

13. Do you still have regular menstrual periods?

Yes
No

14. Do you use birth control pills?

Yes
No