T5 Healthy Living&3153;:Cholesterol Survey
First Name:*
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How would you rate your cholesterol?
Please Select
Good/Average(less than 200)
At Risk/Borderline(200-240)
High(240-280)
Very High(280+)
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How would you rate your LDL
(bad) cholesterol?
Please Select
Good/Average(less than 130
At Risk/Borderline (130-160)
High(170-200)
Very High(200+)
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How often do you have your
Cholesterol checked?
Please Select
Yearly
twice a year
Almost never
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Based on your family history
are you at risk for Heart Disease?
Yes
No
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Based on your family history
are you at risk for a stroke?
Yes
No
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What do you do to manage
your Cholesterol?
(check all that apply)
Diet
Exercise
Medication
Nothing
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If medication, which one(s)?
(Click all that apply)
Crestor
Lescol XL
Lipitor
Lopid
Mevacor
Niaspan
Pravachol
Vytorin
Zetia
Zocor
Other
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