STROKE RISK ASSESSMENT FORM
Name
:
Age
:
Gender
:
--Select--
Male
Female
Weight
:
lbs.
Height
:
'
"
Self Family Medical History
(check all that apply to you or to any blood relative (parent, sibling, etc.
Previous Stroke
Previous Mini-Stroke/TIA
High Blood Pressure (current or history of)
Previous Heart Attack
Heart Disease
Heart Surgery
Diabetes
High Blood Cholesterol (current or history of)
Current Smoker, how much
(packs/day) ?
Former smoker? Duration of smoking
years
Alcohol Consumption, how much
(drinks/day)
Assessments:
Blood pressure
:
Systolic/ Diastolic
Pulse Rate
:
Regular
Irregularly irregular
Cholesterol
:
--HDL
:
--LDL
:
Glucose Level
:
mg/ dL
If you have any of the symptoms below (check all that apply)
• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause
Action
Call the i-Stroke Customer Hotline
GMA : (02) 811 4723
Provincial : 1 800 1888 4723
Review this form with your doctor
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