Cardiac Risk Assessment Form
Patient Information
Full Name
Date of Birth
Age
Sex
Medical History
History of Hypertension
History of Diabetes
High Cholesterol
Family History of Cardiac Disease
Lifestyle Information
Smoking Status
Alcohol Consumption
Physical Activity
Measurements
BMI
Blood Pressure (mmHg)
Total Cholesterol (mg/dL)
HDL Cholesterol (mg/dL)
Additional Notes