Name *

First Name

Last Name

1. I have hypertension. *

Yes

No

2. I have used/currently use tobacco products. *

Yes

No

3. I occasionally feel light-headed or pass out. *

Yes

No

4. I have diabetes. *

Yes

No

5. My vision in one or both eyes will close like a curtain lowering, then return like a curtain raising. *

Yes

No

6. I have been diagnosed with a stroke previously. *

Yes

No

7. I have been diagnosed with a TIA (transient ischemic attack) previously. *

Yes

No

8. I have family members with suffered strokes or heart attacks before the age of 55. *

Yes

No

9. I would like to sign up for the Old Town M.D. monthly newsletter. *

Yes

No