Q1. In the last 12 months, have you experienced a heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke/Transient Ischemic Attack (TIA) that resulted in any of the following:

1. Was newly diagnosed
2. Prescribed any new medication or any change in dosage, frequency, or type of medication
3. Had any new treatment or any change in treatment, including investigation or testing
4. Referral to a specialist physician for investigation or testing
5. Hospitalization or being seen in the emergency department of a hospital

Q2. Have you experienced the following heart conditions or treatments?

1. Heart bypass, heart valve surgery, or angioplasty more than 10 years ago. Use the date of the most recent procedure.
2. Diagnosed with a heart valve disorder, but not yet had heart valve surgery.

Q4. In the last 12 months, have you:

1. Been diagnosed with or treated for internal bleeding?
2. Been admitted to a hospital for a gastrointestinal disease or disorder?
3. Received treatment, including investigation or testing for any cancer (excluding basal cell and squamous cell skin cancer)?

Q5. In the last 12 months, have you been prescribed or taken any of the following medications?

1. Lasix or furosemide for any reason
2. Prednisone for a lung condition
3. Any form of nitroglycerine for relief of angina pain, including on an as-needed basis

Q6. In the last 12 months, have you been prescribed or taken medications for diabetes and a heart condition? Do not include medication that is prescribed solely for the control of blood pressure. If only 1 condition applies, answer No.

Q1. In the last 12 months, have you experienced a heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke/Transient Ischemic Attack (TIA) that resulted in any of the following:

1. Was newly diagnosed
2. Prescribed any new medication or any change in dosage, frequency, or type of medication
3. Had any new treatment or any change in treatment, including investigation or testing
4. Referral to a specialist physician for investigation or testing
5. Hospitalization or being seen in the emergency department of a hospital

Q2. Have you experienced the following heart conditions or treatments?

1. Heart bypass, heart valve surgery, or angioplasty more than 10 years ago. Use the date of the most recent procedure.
2. Diagnosed with a heart valve disorder, but not yet had heart valve surgery.

Q4. In the last 12 months, have you:

1. Been diagnosed with or treated for internal bleeding?
2. Been admitted to a hospital for a gastrointestinal disease or disorder?
3. Received treatment, including investigation or testing for any cancer (excluding basal cell and squamous cell skin cancer)?

Q5. In the last 12 months, have you been prescribed or taken any of the following medications?

1. Lasix or furosemide for any reason
2. Prednisone for a lung condition
3. Any form of nitroglycerine for relief of angina pain, including on an as-needed basis

Q6. In the last 12 months, have you been prescribed or taken medications for diabetes and a heart condition? Do not include medication that is prescribed solely for the control of blood pressure. If only 1 condition applies, answer No.

Q1. In the last 12 months, have you experienced a heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke/Transient Ischemic Attack (TIA) that resulted in any of the following:

1. Was newly diagnosed
2. Prescribed any new medication or any change in dosage, frequency, or type of medication
3. Had any new treatment or any change in treatment, including investigation or testing
4. Referral to a specialist physician for investigation or testing
5. Hospitalization or being seen in the emergency department of a hospital

Q2. Have you experienced the following heart conditions or treatments?

1. Heart bypass, heart valve surgery, or angioplasty more than 10 years ago. Use the date of the most recent procedure.
2. Diagnosed with a heart valve disorder, but not yet had heart valve surgery.

Q4. In the last 12 months, have you:

1. Been diagnosed with or treated for internal bleeding?
2. Been admitted to a hospital for a gastrointestinal disease or disorder?
3. Received treatment, including investigation or testing for any cancer (excluding basal cell and squamous cell skin cancer)?

Q5. In the last 12 months, have you been prescribed or taken any of the following medications?

1. Lasix or furosemide for any reason
2. Prednisone for a lung condition
3. Any form of nitroglycerine for relief of angina pain, including on an as-needed basis

Q6. In the last 12 months, have you been prescribed or taken medications for diabetes and a heart condition? Do not include medication that is prescribed solely for the control of blood pressure. If only 1 condition applies, answer No.

Q1. In the last 12 months, have you experienced a heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke/Transient Ischemic Attack (TIA) that resulted in any of the following:

1. Was newly diagnosed
2. Prescribed any new medication or any change in dosage, frequency, or type of medication
3. Had any new treatment or any change in treatment, including investigation or testing
4. Referral to a specialist physician for investigation or testing
5. Hospitalization or being seen in the emergency department of a hospital

Q2. Have you experienced the following heart conditions or treatments?

1. Heart bypass, heart valve surgery, or angioplasty more than 10 years ago. Use the date of the most recent procedure.
2. Diagnosed with a heart valve disorder, but not yet had heart valve surgery.

Q4. In the last 12 months, have you:

1. Been diagnosed with or treated for internal bleeding?
2. Been admitted to a hospital for a gastrointestinal disease or disorder?
3. Received treatment, including investigation or testing for any cancer (excluding basal cell and squamous cell skin cancer)?

Q5. In the last 12 months, have you been prescribed or taken any of the following medications?

1. Lasix or furosemide for any reason
2. Prednisone for a lung condition
3. Any form of nitroglycerine for relief of angina pain, including on an as-needed basis

Q6. In the last 12 months, have you been prescribed or taken medications for diabetes and a heart condition? Do not include medication that is prescribed solely for the control of blood pressure. If only 1 condition applies, answer No.

Q1. In the last 12 months, have you experienced a heart or lung condition, shortness of breath, chest pain, stroke or mini-stroke/Transient Ischemic Attack (TIA) that resulted in any of the following:

1. Was newly diagnosed
2. Prescribed any new medication or any change in dosage, frequency, or type of medication
3. Had any new treatment or any change in treatment, including investigation or testing
4. Referral to a specialist physician for investigation or testing
5. Hospitalization or being seen in the emergency department of a hospital

Q2. Have you experienced the following heart conditions or treatments?

1. Heart bypass, heart valve surgery, or angioplasty more than 10 years ago. Use the date of the most recent procedure.
2. Diagnosed with a heart valve disorder, but not yet had heart valve surgery.

Q4. In the last 12 months, have you:

1. Been diagnosed with or treated for internal bleeding?
2. Been admitted to a hospital for a gastrointestinal disease or disorder?
3. Received treatment, including investigation or testing for any cancer (excluding basal cell and squamous cell skin cancer)?

Q5. In the last 12 months, have you been prescribed or taken any of the following medications?

1. Lasix or furosemide for any reason
2. Prednisone for a lung condition
3. Any form of nitroglycerine for relief of angina pain, including on an as-needed basis

Q6. In the last 12 months, have you been prescribed or taken medications for diabetes and a heart condition? Do not include medication that is prescribed solely for the control of blood pressure. If only 1 condition applies, answer No.