Patient Data

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Enter age*: Enter sex: Enter race:

Enter weight*: lbs. Enter height*: feet inches

Enter Systolic: Enter Diastolic: Enter Cholestrol:

Diabetic status of patient:

Select patient's exercise habits:

Select patient's family history:

Select the smoking habits:

For current smokers only:

For former smokers (men only)*:

Amount of cigarettes smoked:

When last time quit:

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All: Age range of 25-74

Males:
1. weight of 100-299 pounds
2. height of 62-76 inches Females:
1. weight of 80-249 pounds
2. height of 58-72 inches
3. no statistics for Former Smoker

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