Cardiac Risk Questionnaire
Self-Assessment Tool
Know Your Cardiac Risk
Answer each section honestly. Your responses help estimate cardiovascular risk factors — a starting point for a conversation with your doctor.
1
Section OneAge & Gender
What is your age?
years
Gender
Used in validated risk scoring models
Male
Female
2
Section TwoBlood Pressure
Do you have high blood pressure (hypertension)?
Yes, diagnosed
Borderline / Pre-hypertension
No
Don't know
Are you currently on blood pressure medication?
Yes
No
What is your typical systolic blood pressure?
The top number, e.g. 130
mmHg
3
Section ThreeCholesterol
Have you been told you have high cholesterol?
Yes
No
Never tested
Are you taking a statin or cholesterol-lowering medication?
Yes
No
4
Section FourLifestyle Factors
Do you smoke or use tobacco products?
Current smoker
Former smoker
Never smoked
How would you describe your physical activity level?
Sedentary (little/no exercise)
Light (1-2 days/week)
Moderate (3-4 days/week)
Active (5+ days/week)
How is your diet overall?
High in processed foods / fast food
Mixed — some healthy, some not
Mostly whole foods, fruits & vegetables
How would you rate your average stress level?
High — frequently overwhelmed
Moderate — manageable most days
Low — generally calm
5
Section FiveMedical History
Have you been diagnosed with diabetes?
Type 1
Type 2
Pre-diabetes
No
Do you have a family history of heart disease?
Parent or sibling with heart attack or stroke before age 65
Yes
No
Unknown
Have you personally experienced any of the following?
Select all that apply
Prior heart attack
Stroke / TIA
Atrial fibrillation
Unexplained chest pain
None of the above
What is your approximate BMI or body build?
Underweight
Healthy weight
Overweight
Obese
Your Estimated Cardiac Risk Profile
LowModerateHighVery High
Suggested Next Steps
⚠ This score is an educational estimate only — not a clinical diagnosis. Please share these results with your doctor.
⚠ For educational purposes only. This questionnaire is not a medical diagnosis and is not a substitute for professional medical advice. Please consult your healthcare team before making any decisions about your health.