Stroke Form - Medijourn

Is your blood pressure mostly higher than 120/ 80mm /Hg?

Yes

No

Have you ever been diagnosed with or currently have atrial fibrillation?

Yes

No

Is your blood sugar level (while fasting) higher than 100 mg/dl?

Yes

No

Are you aware about your Body Mass Index (BMI)?

Yes

No

Is your BMI higher than 25 Kg/m^2?

Yes

No

Does your diet contain high contents of saturated fat, trans fat, Sweetened beverages, salt, and excess calories?

Yes

No

Would you say your total blood cholesterol level is higher than 180 mg/dL?

Yes

No

Have you ever been diagnosed with diabetes mellitus in the past?

Yes

No

Do you indulge in 40 minutes of moderate to vigorous exercise, 3-4 times a week?

Yes

No

Do you have a family history of stroke?

Yes

No

Are you a smoker?

Yes

No

Acknowledgements and Certification

I hereby certify that I have read and acknowledged the entire Hospital's Privacy Policy.

I certify that the personal data filled in this form is true, correct and current. In case I fill in on behalf of other persons, I confirm that I have obtained their consent or have a legal right to disclose their personal data to the Hospital.

Consent
I grant my consent to the Hospital to collect, analyze, process, use and disclose my personal data and send me information about products, services, advertisements, or promotional campaigns that will benefit me through all channels I have provided to the hospital.

Accept

Do Not Accept

Health Risk Assessment

Stroke

Acknowledgements and Certification

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