Healthy Heart Scorecard

Name :

Email :

Phone No :

A : What is your resting pulse (heart rate)?

Less than 80
80-90
91-100
Greater than 100

B : After how many minutes of walking do you start feeling breathlessness?

Never
After 1 hour
After half and hour
After 10 minutes

C : Have you ever felt like you are going to lose consciousness or faint or blackout?

Never
Only once
Very Rare
Quite Often

D :Do you have a history of Hypertension?

No
Mild Hypertension
Moderate Hypertension
Uncontrolled Hypertension

E :What is your HbA1c score?

I am non-diabetic / I Don’t know my HbA1c score
Less than 5.7%
5.7% - 6.4%
Greater than 6.5%

F :How often do you smoke?

Non-smoker
Former smoker. Have Quit now
Regular Smoker
Heavy Smoker

G :Do you drink alcohol?

No I am a non-drinker
Once or twice a month
Once or twice weekly
Regular drinker

H :On a day to day basis, how much physical exercise you do?

More than 1 hour of normal walking or half hour of brisk walking (Greater than10,000 steps)
1 hour walking or half hour of brisk walking (7000-8000 steps)
Occasional walking (5000-7499 steps)
Sedentary Lifestyle ( Less than5000 steps)

I :What is your age?

Less than 40 years
41-50 years
50-60 years
Greater than60 years

J :Does anyone in your family ever suffered from any cardiovascular disease?

Nobody
Distant relative but only mild
Close family but mild
Close family who suffered a heart attack

For any assistance/query, contact us at 9007032832
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