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less than $24,999
$25,000-$40,000
$40K-$50
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Your Heath
1. How do you rate
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2. How do you rate your Weight?
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3. Estimated Weight
4. Do you exercise regularly?
4a . Frequnecy:
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5. How do you rate
your outdoor activity?
5a. Do you remember to wear sunscreen?
What is the SPF
0-9
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6. Do you participate in any of the following
activities?
7. How
do you rate you stress levels?
7a.
What causes your stress (i.e. Work)?
8. How
do you rate you sleep habits?
8a.
How many hours of sleep to you get a night?
9. How do you describe your diet?
10. How often do you see your Dr.?
12. Have
you had/have any of the following conditions?
Additional questions about your high
blood pressure
Do you
treat it with:
Diet/Lifestyle change
Prescription
Both
Which do
RX do you take?
Ace Inhibitors
Capoten (captopril)
Vasotec (enalapril)
Prinivil, Zestril (lisinopril)
Lotensin (benazepril)
Monopril (fosinopril)
Altace (ramipril)
Accupril (quinapril)
Aceon (perindopril)
Mavik (trandolapril)
Univasc (moexipril)
Other
Angiotensin II Receptor Blocker
Cozaar (losartan)
Diovan (valsartan)
Avapro (irbesartan)
Atacand (candesartan)
Other
Beta Blockers
Sectral (acebutolol)
Tenormin (atenolol)
Kerlone (betaxolol)
Zebeta (bisoprolol)
Coreg (carvedilol)
Normodyne, Trandate (labetalol)
Lopressor, Toprol-XL (metoprolol)
Corgard (nadolol)
Levatol (penbutolol)
Visken (pindolol)
Inderal, Inderal LA (propanolol)
Betapace (sotalol)
Blocadren (timolol)
Other
Calcium channel Blockers
Norvasc (amlodipine)
Plendil (felodipine)
DynaCirc (isradipine)
Cardene (nicardipine)
Procardia XL, Adalat (nifedipine)
Cardizem, Dilacor, Tiazac, Diltia XL (diltiazem)
Isoptin, Calan, Verelan, Covera-HS (verapamil)
Other
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