CARDIOVASCULAR RISK

ASSESSMENT QUESTIONNAIRE
Name Date

Cardiovascular Disease: The Number One Killer

Cardiovascular disease is the biggest cause of death in Australia and New Zealand, with one person dying from it every ten minutes. That’s
over 50,000 people per year dying from heart attacks, strokes and blood clots.

What is Cardiovascular Disease?

Cardiovascular disease is the accumulation of fat in the arteries. This fat can cause blood clots to form and if large enough can completely
block a blood vessel. When a clot blocks a blood vessel that is feeding the heart, part of the heart will die. This is called a heart attack. If a
clot blocks a blood vessel connected to the brain, part of the brain will die, and this is called a stroke.

What Causes Cardiovascular Disease?

Most people know that high cholesterol and blood pressure contribute to your risk of a heart attack. Knowing your cholesterol level and blood
pressure is an important step in reducing your risk. However, 50% of people who have heart attacks don’t have high cholesterol or high blood
pressure. There are other important factors that can increase your risk of cardiovascular disease.

You may have risk factors which haven’t been measured by your doctor. For example, you may be under stress, not doing enough exercise,
have poor immune function or be eating too much sugar. These are just a few of the many factors that may cause cardiovascular disease.

How Do I Reduce My Risk of Cardiovascular Disease?

To reduce your risk of cardiovascular disease you need to know what may be putting you in danger and what you can do about it. This
questionnaire will help identify your risk of cardiovascular disease and allow you and your Healthcare Practitioner to decide on the most
appropriate dietary changes, lifestyle changes or supplements to help you maintain a healthy heart and blood vessels.

How Do I Complete This Questionnaire?

• There are two parts to this questionnaire. Part 1 is for you, the patient, to fill in. Part 2 is for your Practitioner to complete.
• This questionnaire may be completed with or without blood test results, however, having the test results is preferable as it will give a
more accurate assessment of your risk. If possible please obtain the following tests from your doctor:
HDL Cholesterol C-reactive protein (hs-CRP)
LDL Cholesterol Homocysteine
Triglycerides Fibrinogen
Apo B / Apo A1 ratio Fasting glucose / Glucose tolerance test / HbA1c
Lipoprotein (a) Blood Pressure

Part 1 - For the Patient:

• You must answer every question.
• Each answer to a question has a numbered score in the right-hand column.
• Read the instructions of every question carefully. For some questions you need to circle only one score, while for others you will need
to circle all the scores that apply to you.
• If you don’t know the answer to a question, circle “Don’t know”.
• At the end of each numbered section, add the scores for that section in the “Total” area provided (shaded).
• Your Practitioner will complete your assessment by filling out Part 2 for you.

Part 2 - For the Practitioner:

• Fill out Part 2 using your patient’s pathology results, or the alternatives offered at each question.
• Write the total scores from each category of Part 1 and Part 2 on the Score Sheet (page 11).
• Based on the total for each category, tick the appropriate “priority” box.
• Add the total column for each category to achieve a total Cardiovascular Score.
• Classify your patients total Cardiovascular Risk based on this score.
PART 1: Patient Questionnaire – Patient to complete 2

Age Lifestyle

Section (a) How old are you? (circle one score) Section (a) Exercise (circle one score)
Moderate exercise is brisk walking, jogging, cycling, swimming,
Under 30 0 playing sports or any exercise that increases breathing and heart rate
30 – 34 1 continuously for at least 20 minutes.
35 – 39 6 Sedentary – moderate exercise less than 20
40 – 44 15 once a week
45 – 49 40 Moderate exercise (average once per week) 1
50 – 54 70 Moderate exercise (average 2 – 3 times per week) -10
55 – 59 100 Moderate exercise (average 4 – 5 times per week) -20
60 – 64 110 Moderate exercise -25
(average 5 or more times per week)
65 – 69 120
70 – 74 130 Section (b) Smoking (circle one score)
75 and over 140
Never smoked 0
Add Age Total:
Ex-smoker 10
Cardiovascular History Current smoker less than 20 cigarettes/day 50
Current smoker more than 20 cigarettes/day 80
Section (a) (circle score if applicable)
Section (c) Passive smoking (a non-smoker exposed to
smoke most days at home or work) (circle one score)
Do you have diagnosed cardiovascular disease, 100
atherosclerosis, previous heart attack, and/or Yes 25
previous stroke
No 0
Have you experienced angina (heart pain) 150
within the last 3 months Section (d) Alcohol (circle score if applicable)
Add Cardiovascular History Total:
Average 0 drinks daily 0
Average 1 drink daily or 7 units per week -10
Family Hisory
Average 2 drinks daily or 14 units per week -5
Section (a) (circle score if applicable) Average 3 or more drinks daily or 21 or more units 5
per week
Mother with Cardiovascular Disease at less than
65 years (high blood pressure, heart attack, 15 Section (e) Alcohol (circle score if applicable)
angina, stroke, hardening of the arteries)
Father with Cardiovascular Disease at less than
Do you consume: 7
55 years (high blood pressure, heart attack, 15 Male: 5 or more drinks
Female: 3 or more drinks
angina, stroke, hardening of the arteries)
in one sitting on a fortnightly or more frequent basis?
Parent with Type II Diabetes (adult-onset diabetes) 15
Add Family History Total: Section (f) Environment (circle score if applicable)

Do you live on a main road? 4

Do you live in a city? 3
Do you live in an industrial area with gas 2
emissions?
Do you work with any chemicals, cleaners, 4
pesticides, petrochemicals, paints, exhausts?
Add Lifestyle Total (section a to f):
PART 1: Patient Questionnaire – Patient to complete 3

Stress

Section (a) Have you experienced any of the following Section (b) Do you participate in any of the following
events in the past 6 months? (circle score if applicable) activities for more than an hour a week? (circle score if
applicable)

Death of spouse 30 Meditation/prayer -5

Death of family member 20 Yoga/stretching/relaxation exercises -5
Divorce/separation 20 Community events/social activities/sports -5
Marital reconciliation 20 Play with pets -4
Jail term 20
Major illness/injury/surgery 20 Section (c) (circle score if applicable)

Marriage 10 Do you feel anxiety, worry, fear, sudden feelings of Weekly or

panic, inability to control breathing and accelerated more:
Dismissal from work 10 heart rate when upset, or recurrent feelings of 40
Retirement 10 unease? Monthly
or more:
Death of a friend 8
20
Illness in the family 8
Do you have feelings of sadness, depression, Weekly or
Sexual difficulties 5 hopelessness, apathy, gloom, helplessness, more:
Pregnancy 5 isolation, loneliness, or lack of interest in social 30
interaction? Monthly
Moving to a new town/city/country 5 or more:
Family/relationship disputes 5 15
Change in financial state 3 Are you easily angered or frustrated, feel resent- Weekly or
ment or hostility towards others or frequently more:
Change of occupation 3 irritable? 25
Change in work responsibilities 3 Monthly
Mortgage 3 or more:
12
Major family events – weddings, births in the 3
immediate family Add Stress Total (section a to c):

Son or daughter leaving home 3

Personal difficulties at work 3
Sleep
Outstanding personal achievement 2
Change in residence 2 Section (a) How many hours of sleep do you have on
Change in schools 2 average per night? (circle one score)
Change in social habits 2
0–4 6
Change in routine 2
5–6 3
Holidays 2
7–8 0
Christmas 2
Minor violations of the law 2
More than 8 hours 4

Section (b) Do you experience? (circle score if applicable)

Snoring 3
Obstructive sleep apnoea 10
Insomnia, difficulty falling asleep or interrupted 3
sleep
Add Sleep Total (section a to b):
PART 1: Patient Questionnaire – Patient to complete 4

Bowel Toxicity Inflammation and Pain

Section (a) Do you regularly experience lower abdominal Section (a) Do you experience any of the following
pain, gas, bloating, diarrhoea, constipation, straining symptoms more than once a month? (circle score if
when passing bowel motions, excessively smelly stools applicable)
and/or a feeling that your bowels do not completely
empty? (circle one score)
Wheezing, sneezing, a runny nose, sore throat, 5
itchy or watery eyes, coughing and/or blocked nose
Yes 8 Heart palpitations or headaches after certain foods 5
No 0
Section (b) Do you experience recurrent pain? (circle one
score)
Section (b) Have you taken the oral contraceptive pill for
more than 6 months in the last year? (circle one score) Daily 30
Yes 5 Weekly 15
No 0 Monthly or less 5
Never 0
Section (c) For what length of time have you been on Add Inflammation and Pain Total
antibiotics in the last year? (circle one score) (section a to b):
Less than 2 weeks 0
2 weeks – 2 months 2
2 – 6 months 5
Longer than 6 months 10
Add Bowel Toxicity Total (section a to c):

Blood Sugar

Section (a) (circle score if any of these statements are

applicable)

Do you feel your energy levels drop within an hour 10

of eating? and /or
Do you experience cravings for sweets or chocolate?
and /or
Do you have headaches or an inability to
concentrate which is relieved by eating?

Section (b) Are you diabetic? (circle score if applicable)

Yes 100
No 0
Add Blood Sugar Total (section a to b):
PART 1: Patient Questionnaire – Patient to complete 5

Diet

(a) How often do you usually eat fried Less than once a week 1 – 2 times a week 3 – 6 times a week Every day
foods?
0 1 5 10
(b) How many serves of bread, pasta, 0 – 1 serves daily 2 serves daily 3 serves daily 4 or more
rice, potatoes or other starchy foods serves daily
do you have a day?
0 0 2 4
(c) How many servings of sweet foods Usually none 1 – 2 serves daily More than 2 serves
like cakes, biscuits, lollies and/or daily
chocolate do you consume a day?
0 2 8
(d) How many teaspoons of sugar do 0–3 4–6 7–9 10 or more
you consume daily in hot drinks,
added to foods, etc.? 0 1 4 7
(e) How often do you usually eat fish? Rarely 1 – 2 times a week 3 – 6 times a week Every day

0 -2 -5 -10
(f) How many pieces of fruit do you Usually none 1 – 3 pieces daily 4 or more pieces daily
usually eat a day?
0 -2 -3
(g) How many serves of vegetables Usually none 1 – 2 serves daily 3 – 4 serves daily 5 or more serves daily
(excluding potatoes) do you usually
eat a day? (1 serve = approximately 0 -3 -5 -10
1 handful)
(h) How many cups of coffee do you Usually none 1 – 2 cups daily 3 – 4 cups daily 5 or more cups daily
usually drink a day?
0 0 2 4
(i) How much soft-drink do you Less than 500 ml 1 – 2 litres per week 3 – 4 litres per week 5 or more litres
consume on average? per week per week

0 2 4 8
(j) How much water do you drink a 0 – 500 ml 501 ml – 1.25 litres More than 1.25 litres
day?
7 3 0
Add Diet Total (section a to j):

End of patient section

 6

Please note any questions for

your Practitioner:
PART 2: Patient Assessment – Practitioner to complete 7

Lipids

Section (a) HDL (circle one score) Section (d) ApoB/ApoA1 ratio (circle one score)

High-density lipoprotein cholesterol less than 20 ApoB/ApoA1 ratio less than 0.8 0
1.1 mmol/L
ApoB/ApoA1 ratio between 0.8 – 1.0 10
High-density lipoprotein cholesterol between 0
1.1 – 1.5 mmol/L
ApoB/ApoA1 ratio between 1.1 – 1.23 20
High-density lipoprotein cholesterol more than -15 ApoB/ApoA1 ratio between 1.24 – 2.0 35
1.5 mmol/L ApoB/ApoA1 ratio more than 2.0 50
Don’t know 0 Don’t know 5

Section (b) Triglycerides (circle one score from one category) Section (e) Lipoprotein (a) (circle one score)

Triglycerides less than 1.0 mmol/L 0 Lipoprotein (a) less than 30 mg/dL 0
Triglycerides between 1.0 – 2.0 mmol/L 4 Lipoprotein (a) more than 30 mg/dL 10
Triglycerides between 2.1 – 3.0 mmol/L 15 Don’t know 5
Triglycerides between 3.1 – 5.0 mmol/L 20 Add Lipid Total (section a to e):
Triglycerides more than 5.0 mmol/L 25
OR
Blood Pressure
HemaviewTM results:
No chylomicrons after 6 hour fast 0 Section (a) Systolic blood pressure (circle one score from
Presence of chylomicrons after 6 hour fast 12 one category)
OR Less than 120 mm Hg 0
Don’t know (no blood test or Hemaview TM
5 120 -129 mm Hg 8
results for triglycerides/chylomicrons)
130 -139 mm Hg 20
Section (c) LDL (circle one score) 140 -160 mm Hg 40
More than 160 mm Hg 60
Low-density lipoprotein cholesterol less than 0
2.5 mmol/L Don’t know 10
Low-density lipoprotein cholesterol between 5 Add Blood Pressure Total:
2.5 – 3.3 mmol/L
Low-density lipoprotein cholesterol between 20
3.4 – 4.1 mmol/L
Low-density lipoprotein cholesterol between 30
4.2 – 4.9 mmol/L
Low-density lipoprotein cholesterol more than 50
4.9 mmol/L
Don’t know 5
PART 2: Patient Assessment – Practitioner to complete 8

Inflammation and Pain

Section (a) C-reactive protein: hs-CRP assay (circle one Section (e) Does your patient have any of the following?
score) (circle all applicable scores)

C-reactive protein less than 1.2 mg/L 0 High serum uric acid/gout 15
C-reactive protein between 1.2 – 3.3 mg/L 10 Rheumatoid arthritis 30
C-reactive protein between 3.4 – 5.0 mg/L 20 Systemic lupus erythaematosus (SLE) 60
C-reactive protein more than 5.0 mg/L 34 Any other autoimmune disease e.g. Scleroderma,
Don’t know 5 Sarcoidosis, Multiple sclerosis, Sjogrens
syndrome, Fibromyalgia, Polymyalgia rheumatica, 20
Section (b) Homocysteine (circle one score) Undiagnosed joint or muscle pain unrelated to
injury, Ulcerative colitis, Crohn’s disease
Homocysteine less than 9 µmol/L 0
Asthma, Allergies, Hayfever, Rhinitis, Sinus, Eczema, 12
Homocysteine between 9 – 11.9 µmol/L 2 Psoriasis, Dermatitis, Hives, Urticaria, Skin rashes,
Homocysteine between 12 – 14.9 µmol/L 5 Food sensitivities, Irritable Bowel Syndrome
Homocysteine between 15 – 20 µmol/L 10 History of chronic infection e.g. Epstein Barr virus, 15
Ross River fever, Cytomegalovirus, Barmah forest
Homocysteine more than 20 µmol/L 20 virus, Chlamydia
Don’t know 4 Poor immunity, recurrent infections, frequent catch- 5
ing of colds
Section (c) Fibrinogen (circle one score from one category)
Gum infection, periodontal disease, recurrent 8
Fibrinogen less than 3.0 g/L 0 bleeding gums
Fibrinogen between 3.1 – 4.0 g/L 6 Add Inflammation and Pain Total
(section a to e):
Fibrinogen more than 4.1 g/L 12
OR
HemaviewTM results:
Significant level of fibrin, rouleaux or erythrocyte 8
aggregation
OR
Don’t know 3

Section (d) Urinary pH (circle one score)

Less than or equal to 5.5 8

6.0 - 6.5 4
More than or equal to 7.0 0
Don’t know 2
PART 2: Patient Assessment – Practitioner to complete 9

Liver and Bowel Toxicity Thyroid Function

Section (a) Bacterial balance in the bowel Section (a) (circle one score)
(circle one score from one category)

Urinary Indican Test results: Normal thyroid function 0

Negative 0 Subclinical hypothyroidism, or basal temperature 14
Score 1 – 2 4 test less than 36.4 or TSH > 2.5

Score 3 – 4 10 Medically diagnosed hypothyroidism or TSH > 4.0 20

OR Medically diagnosed hyperthyroidism or TSH < 0.4 20
If your patient has had a Digestive Stool Analysis, did Don’t know 4
it show the presence of abnormal bacteria, parasites Add Thyroid Function Total:
or yeasts in the bowel?
Yes 10
No 0 Blood Sugar
OR
Section (a) Use one of the following categories with recent
Don’t know 3 results (within the last 12 months) to assess blood
Add Liver and Bowel Toxicity Total: glucose control (circle one score from one category)

Fasting blood glucose:

Stress
Fasting glucose less than 5.5 mmol/L 0
Section (a) (circle one score from one category) Fasting glucose 5.5 – 6.9 mmol/L 20
Fasting glucose more than 6.9 mmol/L 50
If your patient has had cortisol levels tested in blood
or saliva, do they have? OR
Abnormal cortisol levels, rhythms or ratios 12 Glucose tolerance test
Normal cortisol 0 2 hr glucose less than 7.8 mmol/L 0
OR 2 hr glucose 7.8 – 11.0 mmol/L 20
Don’t know 4 2 hr glucose more than 11.0 mmol/L 50
Add Stress Total: OR
HbA1c
HbA1c less than 5.0% 0
HbA1c 5.0 – 5.4% 15
HbA1c 5.5 – 7.0% 25
HbA1c more than 7.0% 50
OR
Don’t know 15
Add Blood Sugar Total:
PART 2: Patient Assessment – Practitioner to complete 10

Waist Measurement

MEN WOMEN

Metabolic
Syndrome
102 cm 88 cm

High Risk
94 cm 80 cm

Low Risk

* Measurement average for European, African and Middle

Men Eastern descent. For other groups, see table below.
Waist < 94 cm 0
Country/ethnic Waist circumference
Waist 95 - 101 cm 25 group (as measure of central obesity)

Waist > 102 cm 50 Europids Male > 94 cm

Female > 80 cm
Women South Asians Male > 94 cm
Waist < 80 cm 0 Female > 80 cm
Chinese Male > 94 cm
Waist 81 - 87 cm 25 Female > 80 cm

Waist > 88 cm 50
Ethnic South and Central Americans Use South Asian recommendations until
Add Waist Measurement Total: more specific data are available

Weight Management (Men) Weight Management (Women)

BIA – Bioimpedance Analysis BIA – Bioimpedance Analysis

Percentage of body fat less than 15% 0 Percentage of body fat less than 25% 0
Percentage of body fat is between 15 – 20% 2 Percentage of body fat is between 25 – 29% 2
Percentage of body fat is between 21 – 26% 10 Percentage of body fat is between 30 – 35% 10
Percentage of body fat more than 26% 25 Percentage of body fat more than 35% 25
Don’t know 2 Don’t know 2
MEN: Add Weight Management Total: WOMEN: Add Weight Management Total:
SCORE SHEET 11

CATEGORY SCORE PRIORITY (Mark appropriate

Part 1 Part 2 TOTAL
category based on total score)
Age Not a modifiable risk factor
Cardiovascular history  Low: (0 – 30)
 Medium: (31 – 50)
 High: (51 and above)

Family history Not a modifiable risk factor

Lifestyle  Low: (-35 – -10)

 Medium: (-9 – 21)
 High: (22 and above)
Stress  Low: (-19 – 20)
 Medium: (21 – 40)
 High: (41 and above)

Sleep  Low: (0 – 5)
 Medium: (6 – 11)
 High: (12 and above)
Bowel toxicity  Low: (0 – 3)
 Medium: (4 – 9)
 High: (10 and above)
Blood sugar  Low: (0 – 19)
 Medium: (20 – 49)
 High: (50 and above)
Inflammation and Pain  Low: (0 – 19)
 Medium: (20 – 42)
 High: (43 and above)
Diet  Low: (-19 – 6)
 Medium: (7 – 13)
 High: (14 and above)
Lipids  Low: (-15 – 9)
 Medium: (10 – 34)
 High: (35 and above)
Blood pressure  Low: (0 – 9)
 Medium: (10 – 29)
 High: (30 and above)
Thyroid function  Low: (0 – 7)
 Medium: (8 – 13)
 High: (14 and above)
Weight management  Low: (0 – 11)
 Medium: (12 – 25)
 High: (26 and above)

Add Total Cardiovascular score:

Total cardiovascular risk

RISK SCORE RELATIVE RISK
Low risk: -88 – 100 less than 1
Moderate risk: 101 – 220 1 – 3 risk
High risk: 221 – 350 3 – 5 risk
Very high risk: 351and above 5+ risk
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MET2422 - 01/10 - CHDQ