Risk Quiz | Kettering Health

How often do you smoke?

I have never smoked
It's been more than 2 years since I smoked
I smoke a cigar, pipe, or less than 10 cigarettes per day
I've smoked 1/2 pack to 1 pack per day for 5-10 years
I've smoked 1-2 packs per day for 10-20 years
I've smoked more than 2 packs per day for over 20 years

Has your doctor ever had concern about your blood pressure?

No, my blood pressure is normal
Yes, my doctor has expressed concern that my blood pressure is occasionally elevated
Yes, I am on medication to control my high blood pressure

How often do you exercise?

(Activities such as walking, swimming, biking, rowing etc. performed at a brisk pace for 30 minutes non-stop)
5-6 times per week
3-4 times per week
1-2 times per week
No regular exercise

Are you overweight?

No, I'm at an ideal weight or 5% below
Yes, I'm 5-15 pounds overweight
Yes, I'm 16-25 pounds overweight
Yes, I'm 26-50 pounds overweight
Yes, I'm more than 50 pounds overweight

Age/Sex

Female under 55
Male under 45
Female 55-59
Male 45-59
Male or female age 60 or over

Does your family have a history of heart disease?

No one in my family has a known history of heart disease
I have one relative over 60 with heart disease
I have one relative under 60 with heart disease
I have two relatives under 60 with heart disease
I have three or more relatives under 60 with heart disease

How many servings of red meats, organ meats, fried foods, high-fat dairy, or high fat sweets do you eat per week?

0-2 servings
3-7 servings
More than 7 servings

Do you have diabetes?

No
Yes, and I control it by my diet
Yes, and I am on medication to control my blood sugar

How often are you stressed?

Seldom stressed and cope very well
Sometimes stressed and cope fairly well
Often stressed and frequently have trouble coping
Heavily stressed and have trouble coping at all times
Excessively stressed and am unable to cope

Outpatient Scheduling Questions

This form is NOT for initial scheduling purposes.

Are You At Risk Quiz

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