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Pre-Evaluation Questionnaire

Name*
First Last
Phone*
Email*
Company*
Do you smoke? [V15.82]*
- Yes
- No
Has anyone in your immediate family (father, mother, sister, brother, grandparent(s), aunts or uncles (blood relatives) been diagnosed with cardiovascular disease?*
- Yes
- No
Do you have diabetes?*
- Yes
- No
Do you have elevated cholesterol or triglycerides?*
- Yes
- No
Do you have hypertension, high blood pressure, or take blood pressure medicine?*
- Yes
- No
Do you have varicose veins?*
- Yes
- No
Do you ever stand up and get light headed?*
- Yes
- No
Do you have erectile dysfunction? (Men)
- Yes
- No
Do you have heart palpitations or heart “utters“?*
- Yes
- No
Have you ever had a sudden loss of vision in one eye, usually lasting only seconds?*
- Yes
- No
Have you been diagnosed with any type of heart ailment, heart disease, or cardiovascular disease?*
- Yes
- No
If you have you been diagnosed with any type of heart ailment, heart disease, or cardiovascular disease, what?
Do you have, or easily get, cold hands or feet?*
- Yes
- No
Do you have gum disease, gingivitis, or periodontitis?*
- Yes
- No
When walking or exercising, do you get leg pain or cramping?*
- Yes
- No
Do you have any sleep issues?
- Yes
- No
Height ______ft. _______in.*
Birthday*

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