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Risk Assessment Questionnaire for
Heart Attacks, Strokes, and Dementia

Research shows that almost half of otherwise ‘healthy’ American adults may have some degree of plaque already forming in their arteries, and not even know it. It's even been found to be present in 1 out of 6 otherwise healthy teenagers! While most do not realize it, events like heart attacks and strokes, as well as a significant degree of future risk for dementia, do not require large amounts of plaque to happen. One of my main professional goals is to help people prevent health disasters well before they start. Please take the questionnaire below and if your score is anything other than excellent, schedule an appointment to help further assess your level of risk and how to learn how to improve upon it.

 

  1. How old are you?

    1. Male < 55yo- 1 point

    2. Female < 65yo- 1 point

    3. Male at least 55yo- 4 points

    4. Female at least 65yo- 4 points

  2. Do you have a family history of heart attack, stroke, Alzheimer’s, or dementia?

    1. No- 0 points

    2. Yes- 4 points

  3. What is your waist circumference (wrap a tape measure all the way around your body, level with your belly button)?

    1. Female <35 in- 0 points

    2. Male <40 in- 0 points

    3. Female at least 35 in- 4 points

    4. Male at least 40 in- 4 points

  4. What is your resting pulse rate?

    1. < 60 beats per min (BPM)- 0 points

    2. < 75 BPM- 1 point

    3. At least 75 BPM- 2 points

  5. What is your blood pressure?

    1. < 120/80- 0 points

    2. 120/80 to 139/89- 3 points

    3. 140/90 or higher- 4 points

    4. Taking blood pressure medication- Count yourself as 3 points

  6. What is your total cholesterol level?

    1. < 160- 0 points

    2. < 200- 1 point

    3. > 200- 3 points

    4. If taking cholesterol lowering medication- Count yourself as 3 points

  7. What is your LDL cholesterol?

    1. < 70- 0 points

    2. 70 to 99- 1 point

    3. 100 to 130- 3 points

    4. > 130- 4 points

  8. What is your triglyceride level?

    1. < 100- 0 points

    2. 101 to 150- 1 point

    3. > 150- 3 points

  9. Do you have high blood sugar/diabetes?

    1. No- 0 points

    2. Yes, prediabetes- 3 points

    3. Yes, diabetes- 4 points

  10. Do you have frequent bleeding gums?

    1. No- 0 points

    2. Yes- 2 points

  11. Which best describes your sleep patterns?

    1. I sleep soundly 6-8 hrs/night- 0 points

    2. I sleep restlessly 6-8 hrs/night- 2 points

    3. I sleep < 6 hrs/night or more than 9 hrs/night- 3 points

  12. Do you snore?

    1. No- 0 points

    2. Yes, occasionally- 1 point

    3. Yes, frequently and loudly- 3 points

    4. Yes, and I have sleep apnea- 4 points

  13. Do you have rheumatoid arthritis, or any other inflammatory autoimmune disease like psoriasis, or lupus?

    1. No- 0 points

    2. Yes- 4 points

  14. What is your vitamin D level?

    1. >50- 0 points

    2. 30 to 49- 1 point

    3. < 30- 3 points

  15. Do you get true migraines?

    1. No- 0 points

    2. Yes, with no migraine aura- 2 points

    3. Yes, with a migraine aura- 3 points

  16. How would you characterize your ability to cope with stress? 

    1. I’m pretty laid back most of the time- 0 points

    2. I have healthy ways to cope with stress- 1 point

    3. Sometimes people say I seem stressed- 2 points

    4. I feel stressed and anxious most of the time- 4 points

  17. Do you spend 8 or more hours per day sitting?

    1. No- 0 points

    2. Yes- 4 points

  18. How much exercise do you get?

    1. At least 30min 5 to 7 days/week- 0 points

    2. At least 30min 2 to 4 days/week- 1 point

    3. 30min once or twice a week- 2 points

    4. I do not exercise regularly- 4 points

  19. Do you use any type of nicotine product?

    1. No- 0 points

    2. Yes, but quit > 5 yrs ago- 1 point

    3. Yes, but quite < 5 yrs ago- 2 points

    4. No, but I am exposed to secondhand smoke regularly- 3 points

    5. Yes- 4 points

  20. Do you drink regular or diet soft drinks, juice, or energy drinks?

    1. No- 0 points

    2. Rarely- 1 point

    3. Once a week- 2 points

    4. More than once a week- 3 points

  21. I eat processed/simple/refined carbohydrates/sugars:

    1. Rarely- 0 points

    2. 1-2 times a week- 1 point

    3. 3-4 times a week- 2 points

    4. 5 times a week- 3 points

    5. Daily- 4 points

  22. I eat red meat/processed meat, eggs, butter and/or cheese:

    1. Once a week or less- 0 points

    2. 1-2 times a week- 1 point

    3. 3-4 times a week- 2 points

    4. 5 times a week- 3 points

    5. Daily- 4 points

  23. I eat fried foods/oily processed foods:

    1. Once a week or less- 0 points

    2. 1-2 times a week- 1 point

    3. 3-4 times a week- 2 points

    4. 5 times a week- 3 points

    5. Daily- 4 points

  24. Females Only: Did you experience high blood pressure, pre-eclampsia, or gestational diabetes during pregnancy?

    1. No- 0 points

    2. Yes- 4 points

  25. Males and Females: Have you experienced onset of erectile dysfunction/inability to orgasm with increasing age?

    1. No- 0 points

    2. Yes- 4 points

 

What your score means

  • 2 to 4 points- Congratulations! You’re likely doing great and your risk is likely low. Let's keep it that way by adapting even more proactive steps to heart and brain health in your life!

  • 5 to 10 points- You have a few risk factors, and you would benefit from a better set of risk assessment tests and learning how to make sure you keep your heart and brain healthy as you age.

  • 11 to 20 points- You have definite risk factors for arterial disease which can cause heart attacks, strokes, and/or dementia. Please consider further evaluation via thorough risk assessment.

  • 21-39 points- Your risk is significant. Making an appointment for further discussion and evaluation is highly recommended.

  • 40 points or higher- You’re at very high risk for a cardiovascular event in the future. A comprehensive evaluation as soon as possible is strongly recommended. 

(*This questionnaire is adapted from Drs. Brad Bale and Amy Doneen)

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