Welcome to the Better Heart Health - Initial Patient Self-Assessment.  This questionnaire will take approximately 20 minutes to complete.  You will need to complete this questionnaire in a single session as it can not be saved and completed later.  By completing this questionnaire your pharmacist will be able to better understand your condition to better inform you or recommend changes that will benefit you in managing your heart health.   Your responses are strictly confidential and will only be used by the pharmacist providing heart health consultations with you.

Once the questionnaire is finished please click submit.  A copy of the questions and your responses will be e-mailed to you.
*a red asterisk indicates a response is required

 

Better Heart Health Patient Self-Assessment

Patient Consent

The information collected as part of this online self-assessment questionnaire contains confidential personal health information; therefore it is important for you to understand the privacy and security issues involved. All of your personal health information will be stored using state of the art secure technology to ensure security and confidentiality. Your employer will not receive any personal health information that will identify you as an individual. The pharmacist providing Chronic Disease Management Services will only receive a copy of your results to discuss with you during your consultation and MHCSI will use non-identifying data combined with others in a large statistical database for aggregate reporting only.

By clicking below, you are agreeing to the above statements and release your information to be used only as specified above.

Patient Information

First
Last
(example: Lawtons Drugs Main Street, Dartmouth; Sobeys Pharmacy Mumford Road, Halifax)

Demographics

History

Check all that apply
(If your height falls in between, please round up)
example: 175 lb.
Check all that apply
Check all that apply
Check all that apply

Risk Score and Cardiovascular Age

The Canadian Cardiovascular Society recommends that a cardiovascular assessment be completed every 5 years for men and women age 40 - 75 using the Framingham Risk Score or the Cardiovascular Life Expectancy model to guide therapy to reduce major cardiovascular events. A risk assessment may also be completed whenever a patient's expected risk status changes.

To calculate your Cardiovascular Age, visit the website by clicking ---------> Cardiovascular Age. When you click on the link, a new web browser page will open, you will not lose your place on the Better Heart Health Self-Assessment page. Follow the instructions and answer the questions, the website will generate your Cardiovascular Age. Enter your Cardiovascular Age below.

The website link to calculate your cardiovascular age is included in the above description

To calculate your Cardiovascular Risk Score, visit the website by clicking ---------> Cardiovascular Risk. When you click on the link, a new web browser page will open, you will not lose your place on the Better Heart Health Self-Assessment page. Follow the instructions and answer the questions, the website will generate a Risk Score. Enter your Cardiovascular Risk Score below.

The website link to calculate your cardiovascular risk is included in the above description

Being Active - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Being active means you are taking part in doing things such as jogging, bicycling, golfing, gardening, or walking (without stopping) for at least 30 minutes most days of the week.

0 = Not Important, 10 = Very Important
0 = Note Sure, 10 = Very Sure

Healthy Eating - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Following an eating plan that is good for you includes: not eating too much, counting the amount of carbohydrates you eat, not eating too much fat, keeping an eye on and / or drinking less alcohol. It also means eating fruits, vegetables, whole grains, beans and other foods with high fiber. Following an eating plan that is good for you may also include reaching weight loss goals and limiting your intake of protein and salt you eat.

0 = Not Important, 10 = Very Important
0 = Note Sure, 10 = Very Sure

Taking Medication - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

Taking medication means that you take medicines that have been prescribed by your Healthcare Provider to treat your high blood pressure or cholesterol and other health conditions. These may be pills, inhaled products, creams, or other medicines that you inject. For the next several questions, please answer for all the medicines that you take.

check all that apply
check all that apply
0 = Not Important, 10 = Very Important
0 = Not Sure, 10 = Very Sure

Goal Setting

Self-Efficacy for Heart Health - questions with a 10 point scale where 0 = (lowest level) and 10 = (highest level)

We would like to know how confident you are in doing certain activities. For each of the following questions, please choose the number that corresponds to your confidence that you can do the tasks regularly at the present time.

0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident
0 = Not at all, 10 = Totally Confident

Workplace Productivity and Impairment Score

The following questions ask about the effect of your health condition on your ability to work and perform regular activities.

(Include hours you missed on sick days, times you went in late, left early, etc., because of your heart health. Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
0 = My heart health had no effect on my work, 10 = My heart health completely prevented me from working
(Enter specific number of hours i.e. 1 hour, 2 hours, etc.)
0 = My heart health has no effect on my daily activities, 10 = My heart health completely prevented me from doing my daily activities

This is the end of the questionnaire, please ensure you click SUBMIT before closing your web browser.

Sending