Name:
Phone:
E-Mail Address:
How old are you?
Select Age
POINTS
35-39
0
40-44
1
45-49
2
50-54
3
55-59
4
60-64
5
65-69
6
70 and Over
7
Do you Smoke?
POINTS
Yes
2
No
0
Do you have Diabetes?
POINTS
Yes
2
No
0
What is your blood pressure?
Use Chart to determine correct point value
Systolic
Diastolic
Less than 120
120-129
130-139
140-159
160 or more
79 or less
0
80-84
0
85-89
1
90-99
2
100 or more
3
0
0
1
2
3
1
1
1
2
3
2
2
2
2
3
3
3
3
3
3
Enter the points here:
What is your total cholesterol level?
Total cholesterol (mg/dL)
POINTS
Less than 160
-3
160 - 199.1
0
200 - 239.1
1
240 - 279.1
2
280 and over
3
What is your HDL (Good) cholesterol level?
HDL (Good) cholesterol (mg/dL)
POINTS
Less than 35
2
35-44.1
1
45-49.1
0
50-59.1
0
60 and over
-2
