High Blood Pressure

High blood pressure is called the "Silent Killer." People suffering from high blood pressure often do not display any signs or symptoms of high blood pressure. This questionnaire is designed to help you and your physician identify whether you are currently showing any signs of high blood pressure. This questionnaire does not replace regular visits to your doctor for blood pressure tests but merely lists factors, which could be indicative of high blood pressure 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:
How often do you have your blood pressure checked?

QUESTION 02:
Do you smoke?

QUESTION 03:
Are you overweight? (Take your length in centimetres and subtract 100). This will give your ideal weight.

QUESTION 04:
Do you exercise regularly?

QUESTION 05:
Does anybody in your family suffer or has anyone suffered from high blood pressure?

QUESTION 06:
Are you a diabetic?

QUESTION 07:
What is your age?

QUESTION 08:
Do you stroke your pet dog or cat?

QUESTION 09:
Do you drink lots of coffee/tea/soda?

QUESTION 10:
Do you suffer from high cholesterol?


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