Assessment
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Do you smoke?
Yes
No
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Do you have high blood pressure (hypertension)?
Yes
No
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Are you considered moderately or significantly overweight?
Yes
No
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Have you been diagnosed with diabetes?
Yes
No
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Do you have high cholesterol?
Yes
No
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As an adult, have you ever fainted, blacked out, or lost consciousness without any warning signs?
Yes
No
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Have any of your blood relatives under the age of 60 died suddenly or unexpectedly?
Yes
No
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Do you have, or has your physician ever said that you have, heart failure, weak heart, or a low ejection fraction?
Yes
No
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Have you ever had a heart attack?
Yes
No
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Have you ever been treated with a stent or bypass surgery?
Yes
No
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Have you ever suffered cardiac arrest or do you have a family history of cardiac arrest?
Yes
No
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