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Health Risk Assessment

Note: This survey will not give immediate risk results. Answers are sent to a cardiopulmonary team member for review. They will then contact you to go over your results and discuss services if deemed beneficial. 

This survey will take approximately five minutes to complete.

Demographic Information

Tell us about yourself. 

Health Risk Assessment

Risk Factors

Do you smoke?
Are you diabetic?
Do you have high cholesterol?
Do you have high blood pressure?
Do you have a family history of heart disease?
Do you currently exercise?
Have you ever visited a Cardiologist?
Have you had a heart attack or been diagnosed with a heart disease?
Have you had heart surgery?
Do you experience swelling of your legs, ankles, and/or feet?
Have you ever visited a Pulmonologist?
Do you have a respiratory condition or lung disease?
Do you take medications for a respiratory condition or lung disease?
Do you have symptoms such as shortness of breath, fatigue, cough, and/or wheezing?
Are your activities of daily living limited due to shortness of breath, fatigue, cough, and/or wheezing?

Disclaimer: 

The information contained in this risk assessment is for personal use only. This risk assessment will not provide you with a medical service; it will not diagnose, cure, mitigate, treat, or prevent disease or other conditions; and it is not intended to provide a determination or assessment of your state of health. Always consult a licensed health care professional such as your family physician or a specialist to make health care decisions or before starting any diet or exercise program. We make no warranties, expressed or implied, in connection with the risk assessment or the performance of the risk assessment, and neither the assessment provider, nor related parties, will be held responsible or liable for any costs or damages related to the use of this risk assessment or any information provided therefrom. 

 

The information gathered for this risk assessment is protected by HIPAA regulations. Access to this information is limited to authorized individuals only. Answers to this survey will not be stored or sold to third parties. 

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