Penn State Milton S. Hershey Medical Center

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Heart & Vascular Institute

Patient Resources

Heart & Stroke Test

Are you facing risks for heart disease or becoming a victim of stroke? The Heart & Stroke Test can help you find out. It can identify your risks and suggest how you can change certain risk factors to reduce your overall risk level. Prevention and early detection are the keys to maximizing your health potential!

When you've completed the test below, the results will be transmitted to Penn State Heart and Vascular Institute heart and stroke care professionals for analysis. We'll mail these results back to you at the address you specify. Be sure to include a mailing address in the section below. In addition, we'll include a coupon for a free lipid panel at Hershey Medical Center, which includes total cholesterol, low density lipoproteins, high density lipoproteins and triglycerides. A full lipid panel provides more in-depth information than just the total cholesterol.

Suffering a Stroke does not have to be fatal or debilitating. Learn about a recent Heart & Vascular Institute stroke survivor.

We need your mailing address in order to return your results to you with our recommendations.

If your mailing address is outside the United States of America please enter any info in the "Other Mailing Info" that will help clarify your address.

Demographics

Name (First)	(Last)
Street Address
City		State	Zip
Other Mailing Info	(please use to clarify non-U.S. address info)

Gender:	Male: Female:
Date of Birth	// (month/day/year)
Home Phone	(used only by our staff for questions)

If you are an HMC Employee please enter your Internal mailing code

Family History

Please check one selection

Has your father or a brother had a heart attack before the age of 55, or your mother or a sister before the age of 65?

Yes	No, or don't know

Personal History

Please check one selection

Have you had any of the following events or procedures: angina; heart attack; angioplasty; stent procedure; coronary artery bypass graft; circulation problem in your legs; abdominal aortic aneurysm; stroke; transient ischemic attack (TIA); carotid artery disease.
Yes	No

For Women Only

Please check one selection

Has your menstrual cycle stopped completely?

Yes

Not Applicable

Race

Please check one selection

Are you African-American?

Yes

Are you diabetic, or do you take medications to control your blood sugar?

Yes

Do you know your numbers from a recent lipid panel?

Total Cholesterol (mg/dL)	LDL (bad) Cholesterol	HDL (good) Cholesterol	Triglycerides?
mg/dL	mg/dL	mg/dL	mg/dL

Do you eat at least 5 servings in one week of red meat, eggs, whole milk, cheese and butter?

Yes

Blood Pressure

Please check one selection

During the past year have you been told that your blood pressure is at or higher than 140/90?
Yes	No

Are you taking any medication to help lower your blood pressure?

Yes

Please enter your most recent Blood Pressure if you know it
	(systolic/diastolic)

Smoking

Do you smoke cigarettes?
Yes	No

Exercise

Please check one selection

Do you participate in vigorous endurance exercise such as brisk walking, running, swimming, cycling or other aerobic exercise for at least 30 minutes three or more times per week?
Yes	No

Stress

Please check one selection

Are you frequently tense, angry, irritable or in a hurry?

Yes

Alcohol

Please check one selection

Do you consume more than 3 drinks per day?

Yes

Have you been told you have atrial fibrillation?

Please check one selection

Yes

Have you been told you have a large left ventricle?

Please check one selection

Yes

Personal Information

Height feet inches

Weight pounds

If you would like us to share the results of your Heart Test with your personal physician please include his/her address below. Please be sure to provide the COMPLETE address, as the Post Office will not deliver mail to a partial or incorrect address.
	Physician Name
	Address	Please include complete address

City

State

Zip

If you'd like to be contacted by e-mail, please enter your e-mail address below.
(We do NOT return results of this Heart & Stroke Test by e-mail.)

Thank you for completing The Heart & Stroke Test Questionnaire.
Your confidential report will be mailed to you and will provide important feedback about your results.

Be sure to click the "Submit Form" button below to send your answers to the professionals at
Penn State Heart & Vascular Institute at Penn State Milton S. Hershey Medical Center.

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