Jackson Heart Institute

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What is your age?*

Do you have a Primary Care Physician?*
- Yes, I have a Primary Care Physician
- No, I don't have a Primary Care Physician

My last checkup was:*
- Less than a year ago
- My last checkup was more than a year ago
- My last checkup was more than 2 years ago

Do you or members of your family have a history of heart disease or stroke?*
- Yes
- No
- I don't know
Does your mother or any sisters have a history of heart disease or stroke before the age of 65?
- Yes
- No
- I don't know
Does your father or any brothers have a history of heart disease or stroke before the age of 55?
- Yes
- No
- I don't know

Gender*
- Male
- Female
- Prefer not to answer
Have you reached menopause?
- Yes
- No
Was it less than 10 years ago?
- Yes
- No

Height?
Inches

Weight(Pounds)?*

Ethnicity?*
- White
- African American
- Hispanic/Latino
- Asian, Pacific Islander, American Indian, Alaska Native
- Prefer not to answer

Do you have Diabetes?*
- No
- Prediabetes
- Yes, Type 1
- Yes, Type 2

Do you exercise?*
- No
- Less than 1 hr per week of moderate activity
- More than 1 hr per week of moderate activity
- More than 1 hr per week of rigorous activity

What is your level of stress?*
- None
- Minimal
- Moderate
- Excessive

Do you smoke?*
- Never Smoked
- Quit Smoking (more than 1 yr ago)
- Quit Smoking (less than 1 yr ago)
- Currently Smoking

Do you drink?*
- No
- 1 drink per week
- 3-4 drinks per week
- 5 or more drinks per week

Do you take any of the following medications regularly?
- Blood Pressure?
- Cholesterol?
- Diabetes?
- None of these

Typical systolic blood pressure?*
- Good (120 or lower)
- Moderately High (121 - 139)
- High (140 - 159)
- Very High (160 or higher)
- I don't know

Typical diastolic blood pressure?*
- Good (79 or lower)
- Moderately High (80 - 89)
- High (90 - 99)
- Very High (100 or higher)
- I don't know

Total Cholesterol*
- Good (40 - 199)
- Moderately High (200 - 239)
- High (240 - 279)
- Very High (280 or higher)
- I don't know

HDL (Good Cholesterol)
- Good (40 or higher)
- Risk factor (39 or lower)
- I don't know

LDL (Bad Cholesterol)
- Good (120 or lower)
- Risk factor (121 or higher)
- I don't know

Triglycerides
- Good (149 or lower)
- Risk factor (150 or higher)
- I don't know

Fasting Blood Sugar
- Good (100 or lower)
- Risk factor (101 or higher)
- I don't know

Please Submit this form to GET YOUR IMMEDIATE HEART AGE RESULT
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Email*
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Birthdate
MM slash DD slash YYYY
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