How old are you?

• 20 - 39 years old
• 40 - 59 years old
• 60 - 80 years old

Are you male or female?

• Female
• Male

How would you describe you body and physical condition?

• Lean
• Average
• Overweight
• Obese

How many members of your family have a history of heart disease?

• No known family history of heart disease
• 1 family member 60 years or older with heart disease
• 2 family members 60 years or older with heart disease
• 1 family member younger than 60 years with heart disease
• 2 family members younger than 60 years with heart disease
• 3 or more family members younger than 60 years with heart disease

How often do you eat-out, consume junk food and fast-food?

• Everyday (all meals)
• Everyday (1 meal)
• Alternate days
• Twice a week
• Once a week
• Once a month

In general, which type of foods do you mostly like to eat?

• Bland and boiled
• Salty
• Oily and fatty
• Sweet

Do you a smoke cigarettes or have you used tobacco related products in the past?

• Non-smoker & non-tobacco user
• Ex-tobacco smoker (6 months or more tobacco-free)
• Smoke 1-10 cigarettes a day
• Smoke 11-19 cigarettes a day and/or chew tobacco infrequently
• Smoke 20-29 cigarettes a day and/or chew tobacco infrequently
• Smoke 30-39 cigarettes a day and/or chew tobacco frequently
• Smoke 40 or more cigarettes a day and/or chew tobacco frequently

Are you physically active and exercise regularly or do you have no exercise or irregular physical activity?

• Sedentary without regular exercise
• Sedentary with regular exercise
• Active without regular exercise
• Active with regular exercise

Have you had you blood cholesterol checked recently?

• below 180 mg
• 181mg - 230mg
• 231 - 280mg
• above 281mg
• not checked

Have you had you blood pressure checked recently?

Systolic Blood Pressure in mm/Hg

• below 120 untreated
• 120-140 untreated
• 142-160 untreated
• above 160 untreated
• 120-140 treated
• 142-160 treated
• above 160 treated
• not checked