English Questionnaire


“Take charge of your heart, uncover the risks, and discover the solutions with our cardiovascular wellness program.”

Thank you for taking the time to complete this questionnaire and participating in our heart health program. Your answers to these questions, along with the tests and examinations that will be done in person, will help us evaluate your risk of heart disease and other serious cardiac events and develop a personalized plan of action for you.
Our program includes an initial assessment, which consists of a physical examination, electrocardiogram, and laboratory tests. Based on the results of these tests and examinations, we will provide you with a reliable assessment of your risk factors for heart disease, the probability of cardiovascular events in the future, and any hidden or asymptomatic heart conditions that need to be addressed.
Finally, we will offer recommendations and solutions necessary to maintain heart health and, if necessary, begin treatment of specific conditions. Participants who continue with the program will receive membership points, ongoing support, and guidance, discounts on diagnostic tests, and periodic visits by specialist doctors and healthcare providers.
We believe that by working together, we can prevent heart disease and help you achieve your best possible cardiovascular health.


Do you have a history of high blood pressure?

Have you been diagnosed with diabetes?

Do you have a history of high blood lipid?

Have you ever had a heart attack?

Have you ever had a stroke?

Have you ever do Coronary Angiography?

Have you ever do Coronary CT angiography?

Have you ever do Coronary Angioplasty (stent in the heart vessels)?

Have you ever do Cardiac Surgery?

Have you ever receive Treatment for Cancer?

Do you have a family history of heart disease in your first degree relatives?

Do you have a family history of sudden death in your first degree relatives?

Do you smoke cigarettes?

Have you experienced chest pain or discomfort?

Have you experienced shortness of breath?

Have you experienced palpitations or irregular heartbeats?

Have you experienced sudden loss of consciousness?

 Accepted Insurance Companies