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T5 Healthy Living&3153;:Cholesterol Survey
First Name:*
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Last Name:*
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Street Address:
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City:
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State:
Please Select
Alabama
Alaska
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California
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District of Columbia
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illinois
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West Virginia
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Wyoming
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Zipcode:
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Email Address:*
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Phone:
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Cell Phone:
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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?
Diet
Exercise
Medication
Nothing
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If medication, which one(s)?
(Click all that apply)
Crestor
Lescol XL
Lipitor
Lopid
Lovaza
Mevacor
Niaspan
Pravachol
Vytorin
Zetia
Zocor
Other
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