Healthy Heart Check
NAME: ______________________________________________________DATE: ___ / ___ / ___
(Dr Recommendation) (Dr Referral)
Ideal Below Average Average Above Average *High *Dr Referral?
0-9 0-17 18-25 26-34 35+ (Tick)
1. Cholesterol 5. Diabetes
0 – 4.9 ……………………………………………. 0 Non – diabetic …………………………………..0
5.0 – 5.5…………………………………………... 2 Diabetic ………………………………………. ...4
5.6 – 6.5 ………………………………………….. 5
6.6 and above ……………………………………. 12 6. Age:
Unknown …………………………………………..2 0 – 29 years …………………………………… 0
30 – 39 years ……………………………………1
2. Blood Pressure: 40 – 49 years ……………………………………2
50 – 59 years …(Dr recommendation)……... .4
Systolic: _____________ mmHg 60 – 69 years …(Dr recommendation)…….... 7
Normal 160 …….(Dr referral)……...…………..6* (Mother, Father, Brother, Sister)
No family history of heart disease …………….0
Diastolic: ____________ mmHg Family member had a heart attack or diagnosed
Normal 100…….(Dr referral)…………...........6* Between 56 – 65 years …………5
At or before the age of 55 ……...8
3. Smoking: 8. Personal History:
Never Smoked ……………………………………0 No personal history of heart disease ………...0
Ex-smoker ( 30 mins 3 times a week …0
Weight: ____________________ (kg) Aerobic exercise > 10 mins 1-2 times a week..2
Non – aerobic activity > 2 hours per week ……3
Height: ____________________ (m) Less activity than the above categories………4
BMI (kg/m²): ________________
10. Stress
BMI 40 ……………………………………...........7 High ……………………………………………....4
Very High ………………………………………...5
Healthy Heart Check Form As at April 2010 – Issue 2