Personal Characteristics Age: Gender: Male Female Height (ft, in): Weight (lb): Next Genetics Family History: Family member lived to age 70 with no cardiovascular problems before age 55 Cardiovascular problems of a family member before age 55 2 or more family members with cardiovascular problems before age 55 Do not know mine Blood Pressure: Blood pressure checked regularly with normal readings High blood pressure, on medication and under control High blood pressure, not under control I do not know my blood pressure Coronary artery disease, angina, angina pectoris, or acute coronary syndrome Myocardial infarction or heart attack Congestive heart failure Stroke Emphysema Kidney failure Cancer (except skin cancer) Mild Cognitive Impairment (MCI) Dementia Diabetes: No Low Moderate High Doctor visits I regularly schedule check up with a physician I go to doctor's office when I feel ill I never visit a doctor Over the last year has your health changed ? Much better Somewhat better Same Somewhat Worse Much Worse During the past 30 days, how many times did you feel sad or depressed? Do you ever take medication to sleep? Yes No How many hours do you sleep per night? < 5 6-7 8-9 >9 Previous Next Lifestyle Stress Level: Stress is a positive influence I have my share of ups and downs Stress often overwhelms me Diet: Eat more than 5 portions of fruit and vegetables Average amount of fruit and vegetables and minimum of fast or processed food Eat fast or processed food regularly, minimum fruit and vegetables Exercise Frequency: Daily vigorous exercise Walk minimum 30 minutes 4 days a week Somewhat active Not Active, Sedentary Driving History: No accidents / violations in past 3 years 1-3 accidents / violations in past 3 years 4 or more accidents/violations in past 2 years Convicted in DWI (driving while intoxicated) in past 5 years More than one DWI cinviction in past 5 years Drinking Habits: Do not drink or never drink more than 2 drinks a day 3-4 drinks more than 2 time a week 5 or more drinks at one time more than once a month Smoking Habits: Never smoked Quit more than 2 year ago Quit less than two years ago Smoke less than 2 packs a day Smoke more than 2 packs a day Drugs: Never used drugs for recreation Used drugs for recreation Previous Calculate Longevity
