High Cholesterol

High cholesterol is a consequence of today's fast paced lifestyle. High cholesterol can cause heart disease. The symptoms or high cholesterol are often overlooked until the patient presents with a heart attack, kidney failure, or a stroke. This questionnaire is designed to help you and your physician identify whether you are currently showing any signs of high cholesterol and wheather your lifestyle could contribute to increased cholesterol levels. This questionnaire does not replace regular visits to your doctor cholesterol testing but merely lists factors, which could be indicative of high cholesterol.

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):

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QUESTION 01:
Do you know your cholesterol level?

QUESTION 02:
Do you exercise regularly?

QUESTION 03:
Do you know your daily cholesterol intake?

QUESTION 04:
Do you know if you are eating more saturated fats than unsaturated fats?

QUESTION 05:
Are saturated fats bad for you?

QUESTION 06:
Does anybody in your family suffer from high cholesterol?

QUESTION 07:
Are you a diabetic?

QUESTION 08:
If you do a cholesterol test you should not eat before the test.

QUESTION 09:
Do you get cramps in your legs while walking?

QUESTION 10:
Cholesterol causes:

QUESTION 11:
Has anybody in your family ever had a stroke or heart attack?

QUESTION 12:
Do you use vitamin supplements?


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