Heart Health Check Questionnaire

Have you experienced any of the symptoms below?

Trouble breathing during or after activity or while sitting down Feeling dizzy or lightheaded Fainted or had a blackout Chest pain while active or resting Heart flutters or skipping a beat Still feeling tired after plenty of rest None of the above

How far can you walk without getting short of breath?

I always feel short of breath To the letter box Around the block I don’t get short of breath when walking

When was the last time your doctor:

listened to your heart and breathing with a stethoscope
measured your blood pressure and heart rate
weighed you or measured your waistline
asked about your physical activity

Within the last 6 months Within the last 12 months Over 12 months Never

Do you have a family history of heart disease?

Yes No I’m not sure

Do you smoke?

Yes No

What is your age bracket?

Less than 45 Over 45

Do you have diabetes?

Yes No

What is your post code?

How would you like to get your personalized discussion guide?

Thank you for filling out the questionairre. You can get a copy of your Heart Health Check Questionnaire by clicking one of the buttons below.