Pre-Sea Cardiac Risk Factor Assessment
Personal Information
Full Name
Date of Birth
Age
Sex
Medical History
Hypertension
Diabetes Mellitus
High Cholesterol
Previous Heart Disease
Smoking
Family History of Heart Disease
Duration of Hypertension (years)
Duration of Diabetes (years)
Recent Cholesterol Level (mg/dL)
Physical Measurements
Height (cm)
Weight (kg)
BMI
Blood Pressure (mmHg)
Lifestyle
Regular Exercise
Alcohol Use
Smoking (packs/year)
Alcohol (units/week)
Other Risk Factors
Stress
Sedentary Lifestyle
Obesity
Sleep Apnea
None