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    Your Visit Lifestyle Questionnaire

    Uploaded by

    M Ehab

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Your Visit Lifestyle Questionnaire

    Uploaded by

    M Ehab
    33 views4 pages

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    your-visit-lifestyle-questionnaire

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    Copyright:

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    33 views4 pages

    Your Visit Lifestyle Questionnaire

    Uploaded by

    M Ehab

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Lifestyle questionnaire

    Preparing for your visit | Worksheet

    Staying active and eating well are at the heart of managing heart disease and stroke. Healthy
    lifestyle habits help lower your cholesterol, blood pressure, and the chance of a heart attack
    or stroke. They can also boost your mood, improve sleep and keep you feeling well.

    Use this worksheet to give us a sense of how physically active you are, your efforts to eat a
    heart-healthy diet, and if you use tobacco. This will help us pinpoint areas where you feel like
    you need more advice or support.

    Physical activity and exercise


    Do you have a regular physical activity or exercise routine? ‰ Yes ‰ No
    What types of activities do you do for exercise or physical activity?
    (Circle the activity you enjoy the most.)

    How many days of the week are you physically active?

    1 2 3 4 5 6 7

    How long do you usually exercise (per session of activity)? (Please circle)

    Less than 30 minutes 30 minutes 30-60 minutes 60 minutes or more

    Would you like to be more active?


    ‰ Yes ‰ No
    Are there things that make it hard for you to exercise or be physically active?
    (For example, shortness of breath, fatigue, pain, joint or back issues, lack of time, no safe
    place to exercise, fear, or feeling unsure about how to start or what to do.)

    1. 

    2. 

    3. 

    Preparing for your visit


    CardioSmart.org 1 of 4
    If you’ve had a recent heart attack, had stent(s) placed or underwent heart surgery, were you
    offered cardiac rehab? ‰ Yes ‰ No
    If so, did you participate? ‰ Yes ‰ No
    What is your personal goal when it comes to physical activity and your heart health?

    Heart-healthy eating, nutrition


    What are some of the things you do to eat a heart-healthy diet? (Please check all that apply.)

    ‰ Limit salt (sodium) intake ‰ Eat more vegetables

    ‰ Pay attention to calories ‰ Eat 1-2 servings of fish a week


    ‰ Read food labels (for added sugars, ‰ Bake, broil or grill instead of fry foods
    salt, fats)
    ‰ Use olive oil or vegetable oil instead
    ‰ Pick lean meats (tenderloins, of butter
    skinless chicken, etc.)
    ‰ Cut back on sweets or desserts
    ‰ Limit, or not eat, deli or
    processed meats ‰ Follow a plant-based diet, the Mediterranean
    diet or other eating program
    ‰ Use the plate method (shown below) ______________________________________
    to choose foods and portions
    ‰ Other: _______________________________

    To learn more, visit www.MyPlate.gov.

    Preparing for your visit


    CardioSmart.org 2 of 4
    How often do you eat these foods each day? (For example, how many servings of fruit do
    you have at each meal? A serving size is a standard amount of food, such as a cup or an
    ounce, or what is noted on food packaging.)

    Fresh fruits _____________

    Fresh vegetables _____________

    Whole grains (whole-wheat breads or pasta, bran, barley, oatmeal, brown rice) ____________

    How often do you eat out or buy already prepared meals?

    Sometimes
    Never Once a week Several times a week
    (a few times a month)

    What are your favorite foods to snack on?

    1. 

    2. 

    3. 

    How many alcoholic beverages do you drink each week? _____________

    How many sugar-sweetened beverages do you drink each week (juices, soda, coffee
    creamers)? _____________

    Do you think you are at a healthy weight or would you like to lose weight?

    ‰ I’m happy with my weight.


    ‰ I’d like to lose weight.
    ‰ I’d like advice on how to maintain or not gain weight.
    What is your personal goal when it comes to your diet?

    Preparing for your visit


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    Tobacco use and your heart
    Do you use tobacco (any product, including vaping)? ‰ Yes ‰ Never
    If yes, how often?

    Most days of Several times A few times Only a few times


    Every day
    the week a week a month a year

    Are you around other people who smoke at work or at home? ‰ Yes ‰ Never
    If yes, how often?

    Most days of Several times A few times Only a few times


    Every day
    the week a week a month a year

    If you use tobacco:

    ‰ Yes
    1. Have you tried to stop using tobacco before? ‰ No
    If yes, what have you tried?
    

    2. Have you been offered help to stop using tobacco? ‰ Yes ‰ No


    ‰ Yes
    3. Are you ready to try to quit? ‰ No

    © 2022 American College of Cardiology Z22028

    Preparing for your visit


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