undefined

Heart Health Survey

Take our comprehensive Heart Health Survey to assess your risk factors for cardiovascular disease. Get personalized recommendations and tips to improve your heart health. Don't wait until it's too late – prioritize your heart health today! Start the survey now to take control of your well-being and prevent heart issues in the future.

3 minutes to complete

Questions for Heart Health Survey

Questions

1.

What is your age?

The answer should be a single choice:
  1. Under 30
  2. 30-39
  3. 40-49
  4. 50-59
  5. 60 or older
2.

What is your gender?

The answer should be a single choice:
  1. Male
  2. Female
  3. Prefer not to say
3.

Do you smoke?

The answer should be a single choice:
  1. Yes
  2. No
4.

Do you have a family history of heart disease?

The answer should be a single choice:
  1. Yes
  2. No
5.

Have you ever been diagnosed with any of the following conditions?

The answer should be a multiple choice:
  1. High blood pressure
  2. High cholesterol
  3. Heart disease
  4. Stroke
  5. Heart attack
  6. None of the above
6.

How often do you engage in physical activity (e.g., brisk walking, cycling)?

The answer should be a single choice:
  1. Never
  2. 1-2 times a week
  3. 3-4 times a week
  4. 5 or more times a week
7.

How many servings of fruits and vegetables do you consume daily?

The answer should be a single choice:
  1. Less than 1 serving
  2. 1-2 servings
  3. 3-4 servings
  4. 5 or more servings
8.

On average, how many alcoholic beverages do you consume per week?

The answer should be a single choice:
  1. None
  2. 1-2 drinks
  3. 3-4 drinks
  4. 5 or more drinks
9.

Have you experienced any of the following symptoms in the last month?

The answer should be a single (or) multiple choice by row and column:
Chest pain or discomfort
Shortness of breath
Irregular heartbeat
Dizziness or lightheadedness
Fatigue
Swelling in the legs or ankles
None of the above
Yes
No
10.

When was your last visit to a healthcare provider for a heart check-up?

The answer should be a single choice:
  1. Less than 6 months ago
  2. 6-12 months ago
  3. 1-2 years ago
  4. More than 2 years ago
  5. I have never had a heart check-up
11.

Do you have any known allergies?

The answer should be a single choice:
  1. No
12.

Are you currently taking any prescription medications?

The answer should be a single choice:
  1. No
13.

In the past month, have you felt anxious or worried for more than two weeks in a row?

The answer should be a single choice:
  1. Yes
  2. No

Surveys Similar to Heart Health Survey

  • Mental Health Survey
  • Physical Fitness Survey
  • Nutrition Habits Survey
  • Stress Management Survey
  • Sleep Quality Survey
  • Lifestyle Choices Survey

Here are some FAQs and additional information
on
Heart Health Survey

What is the purpose of the Heart Health Survey?

The purpose of the Heart Health Survey is to gather information on individuals' cardiovascular health habits and risk factors.

Who conducts the Heart Health Survey?

The Heart Health Survey is typically conducted by reputable healthcare organizations or research institutions.

How is the data from the Heart Health Survey used?

The data collected from the Heart Health Survey is used to identify trends in cardiovascular health, inform public health initiatives, and guide medical research.

Want to use this template?

Testimonials

G2 BadgesG2 BadgesG2 BadgesG2 BadgesG2 Badges

What's next? Try out templates like
Heart Health Survey

1000+ Templates, 50+ Categories

Want to create secure online forms and surveys?

Join BlockSurvey.

About Us

BlockSurvey is a privacy-focused platform for collecting data through forms, surveys, assessments, and quizzes. The data collection is end-to-end encrypted, and it ensures complete privacy of your audience from Big Tech. With an array of ready to use templates, it is tailored for the needs of businesses and individuals from Web 3, HR, Mental Health, Sexual Health, Activism and many sensitive areas where data collection needs protection.

SHARE