The Medical City Iloilo | Heart Risk Calculator

Are you ready to know the status of your heart?

Kindly fill out this Patient Information Form for us to get a record of you.

First Name *

Last Name *

Name Suffix

Address

Email address * We'll never share your email with anyone else.

Phone Number * We'll never share your phone number with anyone else.

Data Privay Notice: By filling out this form, you agree to receive marketing-related messages from The Medical City Iloilo in the form of e-mail, text message and other platforms deemed effective by the company. The personal information that may/will be utilized/shared shall include name, contact details and email address.

How’s your heart?

You are few steps closer to knowing how risky are you of getting heart diseases.
Complete the information needed for us to further assess your heart health.

Age *

Gender *

Height *

ft

in

Weight *

kg

If you are a woman, are you in menopausal period?

Have you consulted a Heart Specialist lately?

If yes, who is your heart specialist?

Is your heart in good shape?

Tick the box that applies to your condition.

Have you ever had any of the following conditions or procedures?

Heart attack or Coronary Bypass Surgery

Stroke or Transient Ischemic Attack (TIA)

Peripheral Artery Disease — reduced blood flow in arteries in your legs, arms or other areas

Angioplasty or Stent Placement — a procedure to open narrowed or clogged arteries by placing a small tube (stent) in an artery to keep it open and prevent it from narrowing

Abdominal Aortic Aneurysm — enlargement of the lower area of the major blood vessel (aorta) that supplies blood to the body

Let us know your family’s health history.

Tick the box that applies to your condition.

Have your parents, siblings or children had any of the following at an early age?
(Younger than age 55 for men & younger than 65 for women)

Heart attack or Coronary Bypass Surgery

Stroke or Transient Ischemic Attack (TIA)

Peripheral Artery Disease — reduced blood flow in arteries in your legs, arms or other areas

Angioplasty or Stent Placement — a procedure to open narrowed or clogged arteries by placing a small tube (stent) in an artery to keep it open and prevent it from narrowing

Abdominal Aortic Aneurysm — enlargement of the lower area of the major blood vessel (aorta) that supplies blood to the body

Are you a current or previous smoker?

Have you been told by a doctor that you have diabetes?

Is your “bad” cholesterol elevated?

Do you know your blood pressure?

Systolic:

Diastolic:

Have you been told by a doctor that you have hypertension or taking blood pressure medications?

Do you know your 2D echo result? If yes, was there a mention of left ventricular hypertrophy?

Are you ready to know the status of your heart?

How’s your heart?

Is your heart in good shape?

Let us know your family’s health history.

STAY UP TO DATE