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Coronary artery disease
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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Hello. My name is Daniela and I am a medical student. As part of my final work, I need to collect a few information from respondents to help me create it. The involvement in the poll is completely anonymous and its results will be used exclusively for my work. Thank you for your time in advance.
1
What is your current age?
2
What is your gender?
Select one answer
Male
Female
3
Have you ever been diagnosed with any form of heart disease or cardiovascular condition by a doctor?
Select one answer
Yes
No
Unsure
4
Have you ever been diagnosed with high blood pressure (hypertension) by a doctor?
Select one answer
Yes
No
Unsure
5
Have you ever been diagnosed with high cholesterol (hyperlipidemia) by a doctor?
Select one answer
Yes
No
Insure
6
Have you ever been diagnosed with diabetes ( Type 1 or Type 2) by a doctor?
Select one answer
Yes
No
Unsure
7
Do you currently smoke a cigarettes or use other tobacco products?
Select one answer
Yes
No
I have quit in the past (Please specify when )
8
On average, how many times per week do you engage in at least 30 minutes of moderate-intensity physical activity (e.g., brisk walking, cycling)?
Select one answer
0-1 times per week
2-3 times per week
4-5 times per week
6-7 times per week
More than 7 times per week
9
Would you describe your current diet as generally healthy?
Select one answer
Yes
Mostly healthy
Neither healthy nor unhealthy
Mostly unhealthy
Unhealthy
10
Do you have a family history of heart disease (e. g., heart attack, stroke) in your immediate family(parents,siblings) ?
Select one or more answers
Yes
No
Unsure
(If yes), please specify the relative(s) and their condition(s) if know:
11
In the past year, have you experienced frequent or persistent feelings of stress or anxiety?
Select one answer
Yes
No
Occasionally
12
Have you been diagnosed with any autoimmune diseases (e.g., lupus, rheumatoid arthritis) ?
Select one or more answers
Yes
No
Unsure
(If yes), please specify the condition(s):
13
Have you been diagnosed with any chronic inflammatory conditions(other than autoimmune diseases?
Select one or more answers
Yes
No
Unsure
(If yes), please specify the condition(s):
14
Have you participated in any medical studies or research related to heart health in the past?
Select one answer
Yes
No
Unsure
15
Are you currently taking any medications on a regular basis?
Select one or more answers
Yes
No
(If yes), please list the names of the medications (optional):
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