Stroke Risk Assessment
Please complete this Stroke Risk Assessment to learn your risk of experiencing a stroke in the next ten years. Within seconds you will receive a report of your stroke risk compared to the average stroke risk for Americans of the same age and sex. The results are not meant to predict whether or not you will suffer a stroke, but to assist you in assessing your risk of having a stroke. This assessment should accompany, not replace, a routine physical examination by your family physician.
Name
Address
City
State
Zip
Age
*
Sex *
Male Female
Race *
Caucasian/White African American Asian American Asian/Indian Spanish/Latino American Indian/Alaska Natives Pacific Islanders
2. Do you smoke?*
Yes No
3. Please indicate your lastest blood pressure reading:
Systolic (Top number)
Diastolic (Bottom number)
4. Are you taking medication for high blood pressure?*
5. Have you ever experienced a heart attack?*
6. Have you ever experienced heart failure?*
7. Have you ever suffered a stroke or mini-stroke (TIA)?*
8. Do you have an irregular heart beat (atrial fibrillation)?*
9. Has a doctor diagnosed you with left ventricular hypertrophy?*
(Enlargement of the muscle mass of the left ventricle)
10. Do you have diabetes?*
Not receiving treatment Receiving treatment by controlling diet*
Receiving insulin injections Receiving treatment by medication*
Yes, I am interested in learning more about strokes and stroke prevention.
I would like to attend an education program on stroke prevention. I am interested in other health information.
