About UsPatient CareHeart information CenterEducationResearchSupport The Texas Heart Institute
Women's Heart & Vascular Health
 
Center for Women's Heart & Vascular Health
  Back to previous page

 

Numbers
You Should Know

Go to worksheet.

 
Subscribe
to Women's Heart Health E-News. Please leave this field empty
Information to Share with Your Doctor - Worksheet
| Share

 
know-your-numbers_know-your-heart

"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
(Preeclampsia)?
 _____

Notes:

Do you have
high blood pressure?
 _____

Do you take medicine for
high blood pressure? _____

Do you take medicine
for high cholesterol?
_____

Notes:

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
disease
or peripheral vascular
disease?
 _____

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

Notes:

Have you ever been diagnosed
with Lupus or
Rheumatoid Arthritis?

___Yes  ___No
Notes:

This worksheet is also available as a PDF.

Return to Preventing or Understanding Heart Disease.


Updated October 2013
Top  

If you would like to find a THI heart doctor or need information about keeping your heart healthy, e-mail the
Heart Information Center or call 1-800-292-2221.
 (Outside the U.S., call 1-832-355-6536.)

Texas Heart Institute Heart Information Center
Through this community outreach program, staff members of the Texas Heart Institute (THI) provide educational information related to the prevention, diagnosis, and treatment of cardiovascular disease. It is not the intention of THI to provide specific medical advice, but rather to provide users with information to better understand their health and their diagnosed disorders. Specific medical advice will not be provided and THI urges you to visit a qualified physician for diagnosis and for answers to your questions.
Like us on Facebook Follow us on Twitter Subscribe to us on YouTube Find Us on Flicikr Follow Us on Pinterest Add us on Google+

Please contact our Webmaster with questions or comments.
Terms of Use and Privacy Policy
© Copyright 1996-2014 Texas Heart Institute.
All rights reserved.
This website is accredited by Health On the Net Foundation. Click to verify. U.S. NEWS America's Best Hospitals 2013-14