Page 1 of 2

Kamiloğlu Hospital
Health+
Cardiovascular Risk Scoring Form

This form is designed as a brief preliminary assessment based on widely accepted cardiovascular risk factor approaches, such as INTERHEART.

Its purpose is to help us evaluate possible heart and vascular disease risks and related symptoms at an initial level.

First name

Last name

Phone number

What is your age range?

What is your age range?
A
B
C
D
E

What is your gender?

What is your gender?
A
B

Have you ever been diagnosed with high blood pressure (hypertension)?

Have you ever been diagnosed with high blood pressure (hypertension)?
A
B
C

Do you regularly use blood pressure medication?

Do you regularly use blood pressure medication?
A
B

Which of the following apply to you?

Which of the following apply to you?

Is there a history of early-onset cardiovascular disease in your family?

Is there a history of early-onset cardiovascular disease in your family?
A
B
C

Have you ever experienced any of the following?

Have you ever experienced any of the following?

Have you had any of the following symptoms in the last 3 months?

Have you had any of the following symptoms in the last 3 months?

When was the last time you had a cardiology check-up or a general cardiovascular health screening?

When was the last time you had a cardiology check-up or a general cardiovascular health screening?
A
B
C
D

Do you think your waist circumference or abdominal fat is more than normal?

Do you think your waist circumference or abdominal fat is more than normal?
A
B
C
Thank you for participating in this health screening. Your responses have been received successfully. Our clinical team will review your information, and we will get back to you shortly with a preliminary cardiovascular risk evaluation. If necessary, we will also share guidance regarding the most appropriate next steps for your cardiovascular health.
Pelin Akman, MD
Emergency Department Physician
Kamiloglu Hospital
If you have any questions about this screening, please contact Dr. Pelin Akman via WhatsApp at +905338428459. Written messages only, please.