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Cardiovascular Health Questionnaire

Fill out the form below and click "Submit"
to send us your information for evaluation.

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Name*:

Email*:

Do you have elevated blood pressure?*:

Yes No

Do you have high cholesterol or triglyceride levels?*:

Yes No

Do you have blood sugar issues?*:

Yes No

Do you carry excess belly fat?*:

Yes No

Do you find it difficult to exercise?*:

Yes No

Do you have a stressful lifestyle?*:

Yes No

Do you eat fried foods frequently?*:

Yes No

Do you eat high amounts of sugary foods?*:

Yes No

Do you feel you should eat a more heart-healthy diet?*:

Yes No

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