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Cardiovascular Risk Assessment Questionnaire

Family History (estimated age onset of): Hypertension Angina Heart Attack Stroke Stenting Bypass Dementia Died

Father:

Mother:

Brothers:

Sisters:

Children:

Smoking History: Never / Ex-smoker / Current (If so # per day: )

When Stopped / Years smoked / Average # smoked per day: Pack Years: (years smoked x #day/20)
Diabetes Type 1 / Type 2 / Age diagnosed: Pre-diabetes Y / N

Diabetic Control (HBA1c): Good(<7%) / Average (<8%) / Poor (>8%)
Hypertension Age diagnosed: # Untreated years of hypertension (>130):

Hypertension Control: Good (<120) / Average (<140) / Poor (>140)

Cholesterol Age noted elevated (LDL >4): Age started on Treatment:

Lipoprotein a: Low (<60) / Medium (60-120) / High (>120) Very High (>200) / Extreme (>350) / Note yet tested

Obesity: Weight: Height: BMI: (Wt/(Ht^2)) Waist circumference(wtc): BRI (the new BMI):

BRI calculator:https://www.mdcalc.com/calc/10575/body-roundness-index-bri

Inflammation: Rheumatoid Arthritis / Psoriatic Arthritis / Inflammatory Bowel / Gout / Other:

If on immunological therapy: Injectable / Steroid / Other / None

Autoimmune: Lupus(SLE) / Thyroid / Scleroderma / Other:

Clotting disorder: Prior DVT / Pulmonary embolism(PE) / Provoked: Yes /No

Factor V Leiden / Protein C/S def / Anti-thrombin III def / APLS
Cancer: Prostate / Breast / Lymphoma/leukaemia / Other:

Surgery / Chemotherapy / Chest / Radiotherapy

Mental Health: Bipolar / Schizophrenia / ADHD

Kidney Disease Age told poor (GFR <45) / Haemodialysis / Peritoneal Dialysis

Hormonal: Pre-eclampsia / Gestational Diabetes / Pre-term delivery/Small

Age of menopause: <35 / 35-40 / 40-45 / 45-50 / >50 / N/A

HRT/MHT- Age started: Duration: Ongoing: Yes / No

Artery Imaging: To review where possible

CT Coronary Angiogram / CT Calcium Score / Other CT/Nuclear Scans / invasive angiogram.