Atrial Fibrillation Health Risk Assessment Form * Denotes required fields Please answer all the following questions and then click “Submit” to get your personal risk assessment. * Do you have high blood pressure or take medication for high blood pressure? (Select one) Yes No * Do you smoke or have a long history of smoking? (Select one) Yes No * Do you consume an excessive amount of stimulants such as caffeine? (Select one) Yes No * Do you have an overactive thyroid? (Select one) Yes No * Do you experience periods of extreme stress or fatigue? (Select one) Yes No * Do you have heart disease (valve problems, history of heart attack, heart surgery)? (Select one) Yes No * Do you have chronic lung disease? (Select one) Yes No * Are you over the age of 40? (Select one) Yes No