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Your For Your Heart Health Assessment

In order to give you personalized information relevant to your heart health, we'll need to know a few things about you first. Listed below are a series of questions regarding your health and lifestyle. By answering correctly, we'll be able to provide you with information based on your particular health needs. Once completed, click on the Continue button.

Your answers will be kept strictly confidential — this website does not store "cookies" or collect information of any kind. Because your information is not stored, you'll need to re-enter your responses if you re-take the For Your Heart assessment.

What is your first name? (required)

What is your age?

What is your ethnicity?

How much do you weigh? pounds

What is your height? feet inches

Because of a physical or sensory condition lasting more than 6 months, is your participation in activities of daily life (e.g. work, recreation, mobility, education) limited?

Yes

What disabilities/impairments do you currently experience? (Check all that apply.)

Blindness or low vision

Hearing loss or deafness

Spinal cord injury

Arthritis

Other type of mobility-related disability

None of the above

If you require the use of an aid, such as special equipment or help from others to get around, which aid do you use? (Check all that apply.)

Wheelchair

Walker, Crutches, or Cane

Assistive hearing device

Service animal

Prosthetics or orthotic devices

Friend

Family member

Personal Care Assistant (PCA)

Another type of device

I don't use any aids

When you talk to someone about a concern, to whom do you turn most often?

Spouse

Partner

Friend

Child

Parent

Clergy/Spiritual leader

Support group

Other

Physical therapy (PT) refers to the use of exercises and physical activities to help condition muscles and restore strength and movement. Occupational therapy (OT) refers to skilled treatment that helps people return to tasks around home and at work by maximizing physical potential through lifestyle adaptations and possible use of assistive devices. Are you currently receiving physical therapy (PT) or occupational therapy (OT)?

Yes

How confident are you in your ability to engage in physical/recreational activity

Extremely confident

Very confident

Somewhat confident

Slightly confident

Not at all confident

How confident are you in your ability to make healthy food choices?

Extremely confident

Very confident

Somewhat confident

Slightly confident

Not at all confident

	Yes	No	Dont Know
Have you ever had a stroke?	Yes	No	Dont Know
Have you ever had a TIA (transient ischemic attack), also called a "warning stroke" or "mini-stroke"?	Yes	No	Dont Know
Have any of your first-degree family members (parents or siblings) ever had heart disease or a stroke?	Yes	No	Dont Know

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womenshealth.gov
A federal government website managed by the Office on Women's Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services.
200 Independence Avenue, S.W. • Washington, DC 20201