Checklist of Risk Factors For Heart Disease And Stroke In Women

Filling in this checklist will help you become aware of your personal risks for heart disease and stroke.
Email*
example@example.com
Name*
Age*
Country Of Residence*
Ethnicity*

South Asian (You or your ancestors are from India, Pakistan, Bangladesh, Sri Lanka,Nepal)IndigenousAfricanEuropeanOther
LIFESTYLE FACTORS

(Alcohol intake, binge drinking, sleep, smoking,sitting-time calculator)
Do you drink more than 1 drink a day?*

YesNo
Binge Drinking: This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours.( Brings blood alcohol concentration (BAC) to .08 g/dL. )

YesNo
SLEEP
I sleep for less than 6.5-8 hours every night

YesNo
SMOKING
I currently smoke/ am exposed to second-hand cigarette smoke **

YesNo
"SITTING" DISEASE: SITTING TIME RISK

Please click on the link in the section below to calculate your sitting time risk
Calculate Your Sitting Time Risk
Your Sitting Time Risk
My Sitting Time Risk Is

LOW risk indicates sitting less than 4 hours per dayMEDIUM risk indicates sitting 4 to 8 hours per dayHIGH risk indicates sitting 8 to 11 hours per dayVERY HIGH risk indicates sitting more than 11 hours per day
REPRODUCTIVE HISTORY
Check all that apply.

Early menarche (First menstrual cycles before age 12 )Early age at first birth (First child born before age 18 )History of miscarriageHistory of preterm delivery (Babies born 3 weeks before estimated date of delivery)Delivered small for gestational age babies. ( Baby's birth weight is less than the normal for your country)History of stillbirthHistory of sub-fertility/ or failed infertility treatmentPregnancy Diabetes (GDM)Pregnancy High Blood Pressure/ Pre-eclampsiaEarly menopause (Last menstrual cycle before age 45)Surgical Menopause (Hysterectomy with or without removing ovaries)Diagnosed with endometriosisNot on hormone therapy (if menopausal)On hormone therapy. Using oral estrogens.Using birth control pillsPresently have hot flashes
FAMILY HISTORY
Family history of stroke

YesNo
Family history of heart disease.

YesNo
MEDICAL HISTORY
Check all that apply.*

Type 2 DiabetesHypertension (High Blood Pressure)PCOS (Polycystic Ovarian Syndrome)EndometriosisAtrial Fibrillation (Heart Rhythm Problem)DepressionExposure to trauma ( with or without Post Traumatic Stress Disorder (PTSD))Autoimmune conditions like Lupus, RA, Hypothyroidism (Hashimoto's) Psoriasis etcLiving with obesity/overweightRadiation Exposure to chest ( Breast Cancer Radiotherapy)Cancer Chemotherapy (Past or present)Obstructive Sleep Apnoea (OSA)AnaemiaMigrainePeriodontal Disease or bleeding gumsI don't have any of the conditions listed aboveI don't know
Cancer Chemotherapy

Past /present intake of cancer chemotherapy drugs harmful for the heart.
LIST OF SOME CARDIOTOXIC CHEMOTHERAPY DRUGS
1. Anthracyclines (daunorubicin, doxorubicin, epirubicin, idarubicin)
2. Alkylating agents (busulfan, carboplatin, carmustine, chlormethine, cisplatin, cyclophosphamide, mitomycin)
3. Taxanes (docetaxel, cabazitaxel, paclitaxel)
4. Topoisomerase inhibitors (etoposide, tretinoin, vinca alkaloids)
5. Antimetabolites (cladribine, cytarabine, 5-FU)
Reference: Thomas, Sonia Amin. "Chemotherapy agents that cause cardiotoxicity." US Pharmacist 42.9 (2017): HS24.
VITAMIN DEFICIENCIES, HOMOCYSTEINE
Check all that apply.

High Blood Homocysteine LevelsVitamin D3 deficiencyDon't know
OMEGA 3 INDEX
Omega 3 Index

I don't knowMore than 8%Less than 8%
METABOLIC DYSFUNCTION
Do you currently have or had the following conditions in the past?*

Belly fat. Waist circumference more than 31.5 inches (80 centimetres)Waist /Hip ratio more than 0.8 (Waist measurement at the level of your belly button. Hip measurement at the maximum circumference. W/H ratio=Divide waist size by hip size)High TriglyceridesTriglycerides/HDL-C ratio more than 2.5High Fasting Blood Sugar/Glucose/PrediabetesHigh Fasting InsulinHs-CRP (Blood Test) more than 1I don't know
MOST SIGNIFICANT RISK FACTORS
The most significant risk factors are the following:
1. South Asian Ancestry
2. High Blood Pressure
3. High Sitting Risk Score
4. Type 2 Diabetes
5. Belly Fat or High Waist/Hip Ratio
6. High Blood Triglyceride Levels
7. Smoking
Disclaimer:

This form has not been validated in clinical studies but is based on the author's review of medical literature. Filling in this form and submitting it does not establish a doctor-patient relationship with Dr. Shabnam Das Kar.

By filling out this questionnaire, you are giving Dr. Kar permission to reach out to you in the future.
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LIFESTYLE FACTORS

SLEEP

SMOKING

"SITTING" DISEASE: SITTING TIME RISK

Your Sitting Time Risk

REPRODUCTIVE HISTORY

FAMILY HISTORY

MEDICAL HISTORY

Cancer Chemotherapy

VITAMIN DEFICIENCIES, HOMOCYSTEINE

OMEGA 3 INDEX

METABOLIC DYSFUNCTION

MOST SIGNIFICANT RISK FACTORS

Disclaimer: