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Your For Your Heart Survey

In order to give you personalized information relevant to you and your health, we'll need to know a few things about you first. Listed below is a survey of questions regarding your health and lifestyle. By completing the survey, we'll be able to give you articles based on your particular health needs. After entering your responses, click on the Submit button. Your answers will be kept strictly confidential--this website does not store "cookies" or collect information of any kind.

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

Does your daily diet consist mostly of healthy foods?
By "healthy" we mean foods that are low in fat, saturated fat, cholesterol, and sodium. Some examples are fruits, vegetables, and lean meats, like poultry (without skin) and fish.

I do not eat many healthy foods now, and I do not intend to start in the near future.

I am thinking about starting to eat healthy foods in the next 6 months.

I am planning to start eating healthy foods in the next 30 days.

I have recently begun eating healthy foods (within the last 6 months).

I have been eating healthy foods for more than 6 months.

How would you describe your weight?

I am not at an optimal weight and I do not intend to start working on controlling my weight in the near future.

I have been thinking about starting to control my weight in the next 6 months.

I am planning to start working to control my weight in the next 30 days.

I have recently begun working to achieve or maintain an optimal weight (within the last 6 months).

I have been working to achieve or maintain an optimal weight for more than 6 months.

Do you participate in physical activity of moderate intensity for at least 30 minutes, 5 or more days each week?
By "moderate intensity" we mean things like brisk walking, wheeling, dancing, swimming, cycling, or vacuuming.

I am not currently doing any physical activity of moderate intensity, and I am not thinking about starting a moderate intensity program.

I am thinking about starting a moderate intensity program within 6 months.

I am planning on starting a moderate intensity program within 30 days.

I have recently begun doing physical activity of moderate intensity for 30 minutes at least 5 days a week (within the last 6 months).

I have been doing physical activity of moderate intensity for 30 minutes at least 5 days a week for more than 6 months.

How would you describe your smoking?

I have never smoked.

I am presently a smoker and am not thinking about quitting.

I am thinking about quitting smoking within the next 6 months.

I am planning to quit smoking within the next 30 days.

I stopped smoking less than 6 months ago.

I stopped smoking more than 6 months ago.

How would you describe your blood pressure?

I do not have high blood pressure.

I don’t know my blood pressure.

I am not currently thinking about reducing my high blood pressure.

I am thinking about working to reduce my high blood pressure within the next 6 months.

I am planning to start working to reduce my high blood pressure within the next 30 days.

I have recently begun working on reducing my high blood pressure (within the last 6 months).

I have been working on reducing my high blood pressure for more than 6 months.

How would you describe your cholesterol level?

I do not have high cholesterol.

I don’t know my cholesterol level.

I am not currently thinking about lowering my high cholesterol.

I am thinking about working to lower my high cholesterol within the next 6 months.

I am planning to start working to lower my high cholesterol within the next 30 days.

I have recently begun working to lower my high cholesterol (within the last 6 months).

I have been working to lower my high cholesterol for more than 6 months.

How would you describe your diabetes?

I do not have diabetes.

I don’t know whether or not I have diabetes.

I am not currently thinking about controlling my diabetes.

I am thinking about working to control my diabetes within the next 6 months.

I am planning to start working to control my diabetes within the next 30 days.

I have recently begun working to control my diabetes levels (within the last 6 months).

I have been working to control my diabetes for more than 6 months.

How would you describe your efforts to manage the stress in your life?
Managing stress means taking positive steps to relieve tension, worry and anxiety. These include exercising regularly, doing relaxation techniques or being in a support group.

I am not thinking about managing the stress in my life.

I am thinking about managing the stress in my life within the next 6 months.

I am planning to start a stress management program within the next 30 days.

I have recently begun working on managing the stress in my life (within the last 6 months).

I have been managing the stress in my life for more than 6 months.

How would you describe how you take medications for blood pressure, cholesterol, or diabetes?

I am not currently taking any medications for blood pressure, cholesterol or diabetes.

I am not taking my blood pressure, cholesterol, or diabetes medications as prescribed or directed.

I am thinking about taking my blood pressure, cholesterol, or diabetes medications as prescribed or directed within 6 months.

I am planning to start taking my blood pressure, cholesterol, or diabetes medications as prescribed or directed within the next 30 days.

I have recently begun taking my blood pressure, cholesterol, or diabetes medications as prescribed or directed (within the last 6 months).

I have been taking my blood pressure, cholesterol, or diabetes medications as prescribed or directed for more than 6 months.

Are you currently taking Hormone Replacement Therapy (HRT), which is also sometimes called Menopausal Hormone Therapy? HRT is medication containing estrogen or estrogen and progestin. It is taken to relieve perimenopausal and menopausal symptoms such as hot flashes, night sweats and vaginal dryness.

Yes

No

Don't know

Please check the statement that best describes you.

I have had surgery to remove my uterus, but not both of my ovaries.

I have had surgery to remove both of my ovaries.

I have stopped having periods due to radiation or chemotherapy.

None of the above

Please check the statement that best describes you.

I have passed menopause, meaning I have stopped having periods and my last period was more than 12 months ago.

I am currently experiencing symptoms of perimenopause, the period of gradual changes leading toward menopause, such as irregular periods, hot flashes, night sweats and vaginal dryness. (Irregular periods are periods that do not occur once a month.)

My menstrual cycle is irregular (my period does not come once a month), but this is due to conditions not associated with menopause, such as pregnancy, weight loss/weight gain, ovarian conditions, medications, etc.

My menstrual cycle is regular, meaning that my period comes about once a month.

None of the above describes me.

Have you ever had a stroke?

Yes

No

Don't know

Have you ever had a TIA (transient ischemic attack), also called a "warning stroke" or "mini-stroke"?

Yes

No

Don't know

Have any of your first-degree family members (parents or siblings) ever had heart disease or a stroke?

Yes

No

Don't know

Have you ever experienced any of the following stroke symptoms?

Sudden numbness or weakness of face, arm, or leg, especially on one side of the body.

Yes

No

Don't know

Sudden confusion or trouble speaking or understanding speech.

Yes

No

Don't know

Sudden trouble seeing in one or both eyes.

Yes

No

Don't know

Sudden trouble walking, dizziness, or loss of balance or coordination

Yes

No

Don't know

Sudden severe headache with no known cause.

Yes

No

Don't know

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 - Please answer the next six (6) questions

No - Please skip to the end and click Submit

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? (Check only one response.)

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

No

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

Note: Because your information is not stored, you'll need to re-enter your responses every time you return to the For Your Heart site.

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