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Age: |
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Gender: |
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Height: |
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Weight: |
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Is your waist size greater than 35 inches (women) or 40 inches (men)? |
No Yes |
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Smoker: |
No Yes |
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Diabetes: |
No Yes |
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Do you take medication to treat high blood pressure? |
No Yes |
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Have you had a heart attack, angina, cholesterol blockages in the neck or leg arteries, heart or blood vessel disease events, conditions or procedures? |
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No Yes |
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Is your fasting blood sugar 100 mg/dL or higher? |
No Yes |
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Total Cholesterol (mg/dL): |
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HDL Cholesterol (mg/dL): |
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LDL Cholesterol (mg/dL) |
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Systolic Blood Pressure (mmHg) |
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Diastolic Blood Pressure (mmHg): |
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Are your triglycerides 150 mg/dL or higher? |
No Yes |
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Does anyone in your immediate family have a history of the following: |
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Early heart disease before age 55 (men) or 65 (women) |
No Yes |
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Diabetes |
No Yes |
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Stroke |
No Yes |
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