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.

Self Assessment - Heart Disease
Submit your self assessment form to the Mens Clinic International Doctor for evaluation:
reCAPTCHA