Frankford Hospitals - Center for Gynecology & Women’s Health at Frankford Hospitals

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Center for Gynecology & Women’s Health at Frankford Hospitals

Heart Disease Risk Assessment

Women can answer the following questions to get a sense of their
likelihood of having or developing heart disease.

Are you over age 55?	Yes	No
Do you currently smoke?	Yes	No
Do you have an immediate family member (parent, sibling, or child) who has developed, or died from, heart disease before the age of 65?	Yes	No
Are you overweight?	Yes	No
In terms of your body type, do you carry your weight high in your body rather than low in your body (apple shape rather than pear shape body)?	Yes	No
Would you describe the amount of weekly exercise that you get as low (less than 30 minutes of physical activity on most days)?	Yes	No
Have you already experienced menopause?	Yes	No
Has a blood test in recent years shown that you have high cholesterol?	Yes	No
Has a blood test in recent years shown that your LDL is too high?	Yes	No
Has a blood test in recent years shown that your HDL is too low?	Yes	No
Has a blood test in recent years shown that you have high triglycerides?	Yes	No
Is your blood pressure greater than 140/90 or higher?	Yes	No
Does your diet consist of high-fat foods?	Yes	No
Do you ever experience rapid fatigue, shortness of breath, or light-headedness from modest physical exertion, such as walking or climbing stairs?	Yes	No
In recent years, have you fainted?	Yes	No
Have you ever experienced symptoms of angina (pain, heaviness, or discomfort in your chest – or arm or jaw pain, or pain around the shoulder blades), especially with exertion?	Yes	No
If you previously smoked, has it been less than five years since you quit?	Yes	No
Are you exposed to second-hand cigarette smoke?	Yes	No
Have you gone for years without regular medical check-ups?	Yes	No
Do you have diabetes?	Yes	No
Have you ever had a stroke?	Yes	No
Have you ever had symptoms of a “temporary” or “mini” stroke (temporary weakness in an arm or leg, or difficulty speaking that is otherwise unexplained)?	Yes	No
Would describe the stress levels in your life as high?	Yes	No
Averaged, do you have the equivalent of more than one drink of alcohol per day?	Yes	No

The more often you answered “Yes” to the above questions, the greater your risk for developing or already having heart disease. If you answered “Yes” to questions above, consider discussing heart disease with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.

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