2 Minutes Coronary Health Survey Coronary Health Survey: Would you please take just 2 minutes and provide us with the following information. Read each of the following questions and fill in the blanks or select the answer that best describes you.
Part A: Personal Health History
15. Have you ever been told by a doctor that you have diabetes? Yes No 16. Are you now taking prescribed medications for your diabetes? Yes No 17. Have you ever been told by a doctor that you have heart disease? Yes No Don't Know 18. Smoking Status: Quit smoking, two or more years ago Quote smoking, less than 2 years ago Currently smoke less than 10 cigarettes daily Currently smoke 10 or more cigarettes daily I never smoked
19. Family heart history: Did a parent, brother, or sister ever have coronary heart disease, heart attack or stroke? (before age 55 in men, before age 65 in women) Yes No Don't Know
20. If you were to have a heart attack in the next 10 years, which of the following factors would be important in causing your heart attack or stroke? Check all that apply.
Directions: Please read each of the following statements and fill in the blanks or select the answer that best describes you.
22. Marital Status : Single Married Living with Husband/Partner? Yes No Total number of years of education from first grade Present Employment Status : (check all that apply)
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