Filling in this checklist will help you become aware of your personal risks for heart disease and stroke.

Name: ___________________________

Date: ___________________________

Ethnicity (tick all that apply):

• [ ] South Asian
• [ ] Indigenous
• [ ] African
• [ ] European
• [ ] Other: ____________________

Medical History

Check all that apply.

• [ ] Type 2 diabetes
• [ ] Hypertension (high blood pressure)
• [ ] PCOS
• [ ] Endometriosis
• [ ] Depression
• [ ] Exposure to trauma / PTSD
• [ ] Autoimmune conditions (Lupus, Rheumatoid Arthritis, Hashimoto's, Psoriasis)
• [ ] Living with a higher body weight