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Women's Heart & Vascular Health
Center for Women's Heart & Vascular Health
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You Should Know

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Information to Share with Your Doctor - Worksheet


"It's important for women to have a good working relationship
with their doctor and be aware of their own risk factors
for heart disease."—Dr. Roberta Bogaev

Use the Easy Print Format button below to print the worksheet or use the Email button to share this web page with a friend.
This worksheet is also available as a PDF

At what age did you
begin menopause,
if you have?

Did you have a hysterectomy? _____                
Were the ovaries removed? _____ 
If so, when? _____

Did you take hormones or
hormone replacement therapy? _____
For how many years?_____
Did you take estrogen alone
(for example, Premarin)? _____
Did you take estrogen and progesterone
(for example, Prempro)? _____

Do you have diabetes?

Do you take insulin?_____

Do you have a history of
gestational diabetes? _____

Do you have a history of
high blood pressure
during pregnancy


Do you have
high blood pressure?

Do you take medicine for
high blood pressure? _____

Do you take medicine
for high cholesterol?


Do you smoke? _____

If so do you use tobacco daily? _____

If you no longer smoke, how long
has it been since you quit? _____

Do you have any
family history
of coronary artery
or peripheral vascular

If so, which male relatives under the
age of 55? __________________

If so, which female relatives under the
age of 65? __________________ 

During the past month:
Have you often been bothered
by feeling down, depressed
or hopeless? 
___Yes ___No 
Have you often been bothered
by little interest or pleasure
in doing things?
___Yes ___No


Have you ever been diagnosed
with Lupus or
Rheumatoid Arthritis?

___Yes  ___No

This worksheet is also available as a PDF.

Return to Preventing or Understanding Heart Disease.

Updated January 2015
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