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Stroke Risk Factors


Sacred Heart Regional Stroke Center invites you to complete the Stroke Risk Assessment provided below. You do not need to return this assessment to us; simply fill it out and share it with your physician upon your next visit.

Self Family Medical History

(Check all that apply to you or to any blood relative,
such as parent, sibling, etc.)

Previous Stroke
YES NO

Previous Mini-Stroke/TIA
YES NO

Carotid Artery Disease
YES NO

High Blood Pressure
YES NO

Heart Disease

YES NO

Atrial Fibrillation (heart rhythm disorder)
YES NO

Heart Surgery
YES NO

Diabetes
YES NO

High Blood Cholesterol
YES NO

Current Smoker
YES NO

If you smoke, how many packs do you go through perday?
packs/day

Former Smoker
YES NO

Alcohol Consumption
YES NO

(If you consume alcohol, how many drinks do you drink a day?
drinks/day


Uncontrollable Risk Factors

   
Age 55+
YES NO

African American
YES NO

If you have more than three of the above risk factors, print this page and s

The more risk factors you have, the higher your chances of having a stroke. The best way to prevent a stroke is to reduce your risk factors. Your physician can help you change factors that are related to your lifestyle and your environment.


Stroke Center
Dr. Terry Neil
Patient Testimonial
Resources
Sacred Heart Regional Stroke Center
Symptoms of a Stroke

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