"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 May 2011
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