Full Name
*
Email
*
Phone
*
Address
*
City, State, Zip
*
Does heart disease run in your family?
*
Are you overweight?
*
Do you suffer from high blood pressure?
*
Do you smoke cigarettes?
*
Do you exercise less than three times per week?
*
Do you have a higher than normal level of stress?
*
Do you take a multi-vitamin/mineral supplement daily?
*
Do you consume vegetable oils other than olive oil?
*
Do you take an antioxidant supplement?
*
Have you been diagnosed with arteriosclerosis?
*