Heart Diseases

We are living in a fast moving modern-day society. This lifestyle has caused an increase in the incidence of heart disease. This questionnaire is designed to help you and your physician identify whether your lifestyle could be contributing to an increased risk of heart disease. This questionnaire does not replace regular visits to your doctor for cardiac assessment but merely lists factors, which could be indicative of heart problems.

Each question has several responses from which you are asked to choose the one that best describes your own situation. Please be sure that you select only one response per question.

Please ensure all information is completed correctly in order for us to respond to your assessment promptly.

Your Name (required):

Your Email (required):


QUESTION 01:
1. Do you exercise regularly?

QUESTION 02:
Do you eat healthily?

QUESTION 03:
Do you smoke?

QUESTION 04:
Do you drink more that two alcoholic beverages a day?

QUESTION 05:
Do you take good care of your teeth and gums??

QUESTION 06:
Monounsaturated fats are good to eat.

QUESTION 07:
Do you eat lots of garlic??

QUESTION 08:
Do you ever eat soy-proteins?

QUESTION 09:
Have you ever been on diets where you have lost weight and afterwards picked up weight again?

QUESTION 10:
Do you feel that you are living a stressful life?

QUESTION 11:
Do you think you might be depressed?

QUESTION 12:
Have you ever had to learn how to control your anger?


Submit your self assessment form to the Mens Clinic International Doctor for evaluation: