ocr: Please print and complete this form Appendix I and return to your Pharmacist. Women and Heart Health - Informed Decisions Personal Profile Patient Name: Family History (1st degree relative) Date of Birth: Today's Date Hypertension Yes D No D Pharmacist: Dyslipidemia Yes a Nol a Angina Yes D Nol D Personal History (If yes - specily treatment, details or date) Past Heart Attack Yes a Nol a Ticker Test Score Ifyes, male < 55 yrs? Yes D NoD Height Weight BMI Ifyes, female < 65 yrs? Yes a NoD Allergies Yes D No D TIAS Yes D NoD Hypertension Yes a No a Stroke Yes a NoD Dyslipidemia Yes D NoD Diabete ...
