HEALTH ASSESSMENT FORM
Name :
Contact :
Email :
You can benefit from our Augment NOW (ECP) Program!
1. Tick any symptom if it affects you:
Heavy Sweating
Shortness of Breath
Chest Pain
Pain in the Jaw/ Shoulder/ Arm/ Back/ Stomach
Nausea or Indigestion
Palpitations (Irregular Heartbeat)
Fainting
2. Do you ever get symptoms like the ones you ticked above, when walking for 10 to 15 minutes on level ground or while climbing 10-15 stairs at a normal pace?
Yes
No
Don’t Know
3. Do you feel that these symptoms limit your regular activities like household work, shopping or holidays?
Yes
No
Don’t Know
4. Do you ever get these symptoms at rest, after eating or just after watching television?
Yes
No
Don’t Know
5. Do you ever wake up at night or feel sleepless due to these symptoms?
Yes
No
Don’t Know
6. Have you decreased or started avoiding your regular activities due to these symptoms?
Yes
No
Don’t Know
7. Do you take nitroglycerin tablets before certain activities to prevent these symptoms?
Yes
No
Don’t Know
8. Are you dissatisfied with your current quality of life because of lack of energy, these symptoms or the inability to engage in your daily activities?
Yes
No
Don’t Know
9. Have you ever had bypass surgery, angioplasty or stents implanted?
Yes
No
Don’t Know
10. Do you routinely have Nitrates or Aspirin in your medication?
Yes
No
Don’t Know
11. Do you have:
High Blood Pressure
Diabetes
High Cholesterol
Stress
Bad Eating Habits
Inactive Lifestyle
12. Are you:
Above 40 years
Overweight
Smoking