Coronary risk assessment - self-administered form

Takeheart Health Check       [Heart Attack Prevention Self Administer]

Take the TAKEHEART HEALTH CHECK now!

NB This page uses Java Script. Select here for an alternative page without Java
When you have completed the form you can send it to the Take Heart Health Check mail box by selecting the SEND IT! button. Fields labelled in red constitute the minimum set required to write a report. The more data you supply the fuller the report will be.

But please do not "Send it" unless you have entered all red fields.

Your data will be processed to produce your own personalised report, which will be sent to you by e-mail. Your report will include expert commentary on your health data, and will give and explain your coronary risk score. It will be about 20K long.

The report contains your results, what they mean, what your coronary risk score is, what that means in terms of the probability of a heart attack, what to do about it, a reading list, a "What if?" section and a "While I'm here Doc" section.

The information that you supply to Takeheart is confidential.

Takeheart will come to you, or you can come to Takeheart if you prefer.

Your personal details

Your title
 Your first name
 Your last name
Your address Your zip or post code
Your telephone number
Are you?
Male Female 		Your date of birth
(dd/mm/yyyy)

This is an English site.
Please use the dd/mm/yyyy format
Your e-mail address

Your medical history

Do you currently smoke cigarettes? yes, or no.

How many years have you smoked?  How many do you smoke each day?

Has a doctor told you that you have had (select all that apply):
A heart attack
Angina
Diabetes
Has a parent (mother or father) died of heart trouble?

Your Height & Weight
 In normal indoor clothes and shoes
BMI
Your weight in KgsYour height in Cms Your WeightYour height
Either OrStones LbsFeetInches

BMI? What's that?      BMI and heart attack risk

Is your body build? Large Medium or Small

Your test results
You will have needed to have asked your doctor to perform the following tests and to give you the results.

Essential Items Useful but not essential
Systolic blood pressureDiastolic blood pressureTotal cholesterolPeak flow rate (lungs)Carbon monoxide in alveolar airGGT

Your stress analysis

Please answer the following questions to determine how seriously stress is affecting you.
Check the button if the answer is "Yes". Leave the button unchecked if the answer is "No" or "Don't Know"
Answer the questions with respect to you feelings over the last couple of months.

Have you felt keyed up, on edge?
Have you been worrying a lot?
Have you been irritable?
Have you had difficulty relaxing?
Have you been sleeping poorly?
Have you had headaches or neckaches?
Have you had any of the following?
Trembling, tingling, dizzy spells, sweating, frequency of passing urine or diarrrhoea.
Have you been worried about your health?
Have you had difficulting falling asleep?
Have you had low energy?
Have you had loss of interests?
Have you lost confidence in yourself?
Have you felt hopeless?
Have you had difficulty concentrating?
Have you lost weight (due to poor appetite)?
Have you been waking early?
Have you felt slowed up?
Have you tended to feel worse in the mornings?

The New Sheffield Tables

The New Sheffield Tables are another method of estimating the risk of coronary heart disease. They are complex and require some more information. They are not appropriate for everyone. If you don't know the answers it doesn't matter - just leave them unchecked.

Check the button if the answer is "Yes". Leave the button unchecked if the answer is "No" or "Don't Know"
Please enter your HDL cholesterol value mmols/l

Do you suffer from peripheral vascular disease?
Have you had a non-haemorrhagic stroke?
Have you had a transient ischaemic attack?
Have you microvascular complications of diabetes?
Is there evidence of left ventricular hypertrophy on your ECG (EKG)?
Have you a family history of premature coronary heart disease?
Are you having treatment for high blood pressure?

"While I'm here Doctor"

Some visitors to Takeheart have questions that they ask which are not strictly related to the matters at hand. If you would like a little advice on one or more of the following topics please check them.

Counselling in Norfolk.
Osteoporosis.
Critical illness insurance.
Bone marrow transplants.
Stop smoking addresses.
The British Heart Foundation.
Post-natal depression.
Depression.
Cancer aftercare.
Glaucoma.
Hyperlipidaemia.
Eating disorders.
Migraine.
Phobias.
Stress.
Asthma.
M.E.
Schizophrenia.
Alcohol.
The British Association for Counselling.
Carbon Monoxide.
Tinnitus.
Hormone replacement therapy.
Arthritis.
Carers.
Tattoo removal.

In which language would you like your report written?

How did you come across Takeheart?
Finally Takeheart would appreciate your observations about this form or indeed about Takeheart itself

Thank you - That is the end of the questionnaire

Are you ready to send the data?
Please check the form carefully. Make sure you have filled in all the essential items that are labelled in red. This is the minimum set needed to write a report. The report will be fuller if the other information is supplied as well.

Have you read our Privacy Policy and our Disclaimer?

Have you made an entry in each red field?

or do you wish to reset the form ?

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© G.M.Clayton 1997
GMC Register Number 0147091