Wellspring :: WellspringHeart

	I have been diagnosed with Coronary Artery Disease (CAD) based on non-invasive testing such as exercise testing, nuclear imaging, echocardiogram or other test that clearly demonstrates ischemia.
	I have had Cardiac Catheterization demonstrating CAD.
	I am eligible for bypass surgery/PTCA and may be seeking a clinical alternative.
	I have had Coronary Bypass Surgery.	Date:
	I have had a PTCA/Stent.	Date:
	I have suffered Myocardial Infarction (heart attack).	Date:
	I have been diagnosed with Metabolic Syndrome (Syndrome X):
	I am a man with HDL under 40.
	I am a woman with HDL under 50.
	I am a man with a waist over 40 inches.
	I am a woman with a waist over 35 inches.
	My Triglycerides are greater than 140.
	My Blood Pressure is greater than 130/85.
	My Fasting Blood Sugar (FBS) is greater than 100.
	I am a man over 45 yrs in age.
	I am a woman over 55 yrs in age.
	I have a male relative (father or brother) less than 55 that has had a heart attack or died from a heart attack.
	I have a female relative (mother or sister) less than 65 that has had a heart attack or died from a heart attack
	I have been a smoker within the last five years.
	I have high blood pressure (140/90) or am on blood pressure medication.
	I have low HDL-C (below 40) or am on lipid lowering medications.
	I have elevated levels of Apolipoprotein (a) (above 30).
	My Total Cholesterol is above 240 or am on medication for lipids.
	My LDL is above 160 or am on lipid medications.
	My High Sensitivity C reactive protein is higher than 3mg/dl but less than 10mg/dl.
	My obesity index (BMI) is greater than 30.
	Calculate my Body Mass Index.

	Yes, please contact me regarding WellspringHeart.
	No, I do not wish to be contacted.
	Name: Age:
	Email:
	Phone:



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