Coronary Artery Disease (CAD)

Cholesterol (or total cholesterol / HDL ratio)	Select one ---------- under 160 (< 3) 160-200 (3-4) 200-220 (4-5) 220-240 (5-6) over 240 (> 6)
Blood pressure (systolic / diastolic)	Select one ---------- < 110 / 60-80 110-130 / 60-80 130-150 / 80-90 150-170/ 90-100 > 170 / > 100
Smoking	Select one ---------- never quit more than 10 years ago quit less than 10 years ago around others who smoke occasional 1 pack cigarettes daily 2 or more packs daily
Heredity	Select one ---------- no family history of CAD 1 close relative over 60 with CAD 2 close relatives over 60 with CAD 1 close relative under 60 with CAD 2 or more close relatives under 60 with CAD
Body fat	Select one ---------- very Lean (< 10% fat male; < 16% fat female) lean (10-15% fat male; 16-22% fat female) average (15-20% fat male; 22-30% fat female) above average (20-25% male; 30-35% female) obese (> 25% fat male; > 35% fat female)
Age/Sex Demographic	Select one ---------- female under 45 years female over 45 years male stocky male bald, stocky male
Stress	Select one ---------- no stress occasional mild stress frequent mild stress frequent high stress constant high stress
Physical activity (work, recreation, and exercise)	Select one ---------- intense activity every day moderate activity every day moderate activity most days light activity sedentary

Medical

Medical exam and screening tests (blood pressure, glaucoma, diabetes)	Select one ---------- regular medical exam and tests periodic medical exam sometimes get tests no tests or medical exams
Long-term Medications	Select one ---------- None Brain Cardiovascular (including cholesterol)
Heart	Select one ---------- no history of problems self or family some history rheumatic fever as child, no murmur now rheumatic fever as child, have murmur EKG abnormality or angina
Lung (including tuberculosis and pneumonia)	Select one ---------- no problems some past problem mild asthma or bronchitis emphysema, severe asthma, or bronchitis severe lung problems
Digestive tract	Select one ---------- no problems occasional diarrhea, loss of appetite frequent diarrhea or stomach upset ulcers, colitis, gall bladder, or liver problems severe gastrointestinal disorders
Diabetes	Select one ---------- no problem or family history controlled hypoglycemia (low blood sugar) hypoglycemia and family history mild diabetes (diet and exercise) diabetes (insulin)
Drugs	Select one ---------- seldom use minimal but regular use of aspirin or other meds heavy use of aspirin or other meds regular use of drugs heavy use of drugs

Medical (women only)

Women's Health care	Women only ---------- Regular Pap and breast exam occasional Pap breast and exam never have exam treated disorder untreated cancer
Birth control pill	Women only ---------- never used quit 5 years ago still use, under 30 years of age use pill and smoke use pill, smoke, over 35

Personal

Longevity	Select one ---------- grandparents lived past 90, parents past 80 grandparents lived past 80, parents past 70 grandparents lived past 70, parents past 60 few relatives lived past 60 few relatives lived past 50
Race	Select one ---------- white or Asian black or Hispanic American Indian
Education	Select one ---------- college graduate or skilled craftsman some college or trade school high school graduate grade school graduate
Sleep	Select one ---------- 7-9 hours 6-7 hours more than 9 hours less than 6 hours

Dietary

Diet	Select one ---------- balanced, low-fat (<25%), no refined foods balanced, moderate fat (25-35%), few refined foods balanced, typical fat (< 35%), several refined foods few fruits and vegetables, mostly refined foods fad diet
Breakfast	Select one ---------- daily sometimes none coffee coffee and doughnut
Regular meals	Select one ---------- 3 or more 2 daily not regular starve and stuff
Alcohol	Select one ---------- none 1 drink daily 2 drinks daily 3-6 drinks daily more than 6 drinks daily

Psychological

Happiness	Select one ---------- generally feel very happy feel satisfied unsure about life often unhappy usually unhappy
Depression	Select one ---------- no family history of depression some family history, I feel OK family history and I am mildly depressed sometimes I feel life isn't worth living thoughts of suicide
Anxiety	Select one ---------- seldom anxious occasionally anxious often anxious always anxious panic attacks
Relaxation	Select one ---------- relax or meditate daily relax often seldom relax usually tense always tense
Love and marriage	Select one ---------- happily married married unmarried separated, divorced, or widowed extramarital relationship
Job satisfaction	Select one ---------- enjoy job, see results, able to advance job OK, no results, nowhere to go dislike job hate job
Social	Select one ---------- have some close friends have some friends have no good friends stuck with people I don't enjoy do not have friends

Safety

Driving	Select one ---------- less than 4,000 miles (6,500 km) / year 4,000-8,000 miles (6,500-13,000 km) / year 8,000-12,000 miles (13,000-20,000 km) / year 12,000-20,000 (20,000-32,000 km) miles / year more than 20,000 miles (32,000 km) / year
Seat belt usage	Select one ---------- always most of the time (75%) on highway only sometimes (25%) never
Risk-taking (motorcycle, mountain climb, skydive, higher risk job, etc.)	Select one ---------- never some with careful preparation occasional often try anything for thrills

This questionnaire is designed to help make you aware of factors that can effect your health and longevity. Review your answers and determine which factors you can improve.

Your itemized scores (years)

Location

CAD

Medical

Personal

Diet

Psychological

Safety

TOTAL