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Surveys & Forms

Stroke Risk Assessment

Stroke is the 4th cause of death in America. It is estimated that over 795,000 people are affected by stroke in the United States each year resulting in over 160,000 deaths annually. It is also one of the leading causes of long-term disability with 15-30% of all stroke survivors being permanently disabled.

Are you at risk for stroke?

* Indicates required information

Please provide the following information to help us best serve you.

First Name
Last Name
Email *
Organization
Street
City
State
Zip
Phone
Year of Birth (yyyy) *
Gender *

1. *
Have your parents or siblings ever had a stroke?
      
2. *
Some ethnicities have a higher risk of stroke than others. If you are African American or Hispanic, you have a higher risk of having a stroke than Caucasians.

What is your ethnicity?

If Other, please specify:

3. *
Do you have high blood pressure/have you had it taken in the last 2 years?
4. *
Do you smoke?
      
5. *
If yes, are you interested in quitting smoking?

If Other, please specify:

6. *
Do you have diabetes (have you ever had a fasting blood glucose)?
7. *
Do you have high cholesterol or lipids (have you had a fasting cholesterol test in the last 2 years)?
8. *
Do you have atrial fibrillation (afib)? Afib is an irregular and sometimes rapid heart rhythm that can cause blood clots to form in the heart. These clots can cause a stroke.
9. *
What is your Body Mass Index (BMI)? BMI is a combination of your height and weight. If you have a BMI of 30 or higher, your extra weight is putting your health in danger. If you are Asian, your health may be at risk with a BMI of 27.5 or higher. People who carry too much fat around the middle, rather than around the hips, are more likely to have health problems. Calculate your BMI >>

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