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Cardiac Risk Quiz

Please complete the Cardiac Risk Quiz below and a registered nurse will contact you by phone within three to five business days to discuss your results if they indicate a potential risk for developing heart disease. All information will remain private.



* Indicates required information
First Name * 
Last Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Email Address * 
Phone  
What is your age? * 
What is your gender? 
Have you ever been told you have high cholesterol? 
Have you smoked within the past year? 
Have you been told you have diabetes? 
Are you currently on high blood pressure medicines? 
Has your father, brother, or son experienced a heart attack or stroke before the age of 55 years?  
Has your mother, sister or daughter experienced a heart attack or stroke before the age of 65 years?  
Did you know that Porter Adventist Hospital's Heart Institute is ranked #1 in Colorado for overall Cardiac Care?  
By submitting this form I acknowledge that a registered nurse from the Porter Adventist Hospital Ask-A-Nurse will be contacting me with my results from this quiz. The free Cardiac Risk Quiz is for screening purposes only and is not a diagnostic tool.  
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