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CVD Risk Assessement
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CVD Risk Assessement
Please complete the form below. Mandatory fields are marked
*
Personal Information
Gender
*
Female
Male
Age
*
years
Height
*
cm
Weight
Weight
*
kg
Waist
cm
Smoking Status
Do you currently smoke one or more cigarettes daily?
*
Yes
No
If yes, do you intend to quit within 6 months?
Yes
No
How many times have you attempted to quit in the past ?
times
Blood Cholesterol (mmol/L)
Total Cholesterol
*
HDL
*
LDL
Triglycerides
I don't know my cholesterol values
In the absence of actual measurements, age and gender specific Canadian mean values are used for Total and HDL cholesterol.
Blood Pressure (mmHg)
Systolic
*
Diastolic
*
Do you use blood pressure medication?
*
Yes
No
I don't know my blood pressure
In the absence of actual measurements, age and gender specific Canadian mean values are used for systolic and diastolic blood pressure.
Medical History
Do you have diabetes?
*
Yes
No
if Yes, do you use a glucometer?
Yes
No
- How frequently do you test your blood sugar?
< 1 / week
1-6 / week
1 / day
2-3 / day
4+ / day
Do you have cardiovascular disease ?
*
Yes
No
if YES, wich of the following apply?
- Heart Disease
Yes
No
- Stroke
Yes
No
- Peripheral vascular disease
Yes
No