Cardiac Risk Assessment Form

Cardiac Risk Assessment Form — Form Fields

This healthcare template includes 8 fields. Cardiac risk assessment questionnaire to evaluate cardiovascular risk factors including family history, lifestyle habits, and current symptoms. For use in cardiology and primary care settings. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Age (number, required)
• Gender (multiple choice, required) — options: Male, Female, Other
• Known Risk Factors (select all that apply) (checkboxes, optional) — options: High blood pressure, High cholesterol, Diabetes, Current smoker, Obesity (BMI > 30), Sedentary lifestyle, Family history of heart disease
• Current Symptoms (select all that apply) (checkboxes, optional) — options: Chest pain or pressure, Shortness of breath, Heart palpitations, Dizziness or lightheadedness, Swelling in legs or ankles, Fatigue with exertion, None
• Exercise Frequency (dropdown selection, required) — options: 5+ times per week, 3-4 times per week, 1-2 times per week, Rarely or never
• Current Medications (long text, optional)
• Additional Concerns (long text, optional)