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SECTION 1: RISK FACTORS
	1. What is your gender?
		Female Male
	2. What is your age?
	3. What is your blood pressure?
		Systolic (Top Number) Diastolic (Bottom Number) Do not know
	4. What is your total cholesterol level?
		Less than 200 200-239 240 or more Do not know
	5. Do you currently smoke?
		No Yes
	6. Including beer and wine, how much alcohol do you drink?
		Never drink alcohol Only drink on special occasions Have two or three drinks per week Have one or two drinks per day Have three or more drinks per day
	7. Have you ever been told by your doctor that you have any of the following conditions? Please check all that apply.
		Atrial Fibrillation (a specific kind of irregular heartbeat diagnosed with an EKG) Congestive Heart Failure Heart Attack (myocardial infarction) Angina Other Heart Disease or Heart Surgery Diabetes TIA or mini-stroke I have not been told by my doctor that I have any of these conditions.
	8. Please check any symptoms which you have experienced in the past year.
		Sudden weakness, numbness or paralysis of face, arm or leg; especially on one side of the body Sudden blurred or decreased vision in one or both eyes Sudden difficulty speaking or understanding simple statements Sudden and severe headache; often described as “the worst headache of your life” Sudden dizziness, loss of balance, or loss of coordination, especially when combined with another symptom I haven’t had any of these symptoms
		If you experienced any of the symptoms listed in the previous question, have you discussed them with your physician?
		No Yes
	9. Have you ever had a stroke and/or TIA?
		No Yes
		If you have had a stroke, please indicate when it occurred.
		Within the past 6 months 6 months to 1 year ago 1 to 5 years ago More than 5 years ago
SECTION 2: TREATMENT HISTORY
	10. When was your last visit to a doctor's office?
		Within the past month 1 to 6 months ago 6 months to 1 year ago More than 1 year ago
	11. Has your doctor listened to or checked your carotid (neck) arteries within the past year?
		No Yes Do not know
	12. Do you have carotid artery disease (narrowing of the arteries in the the neck)?
		No Yes Do not know
	13. Have you ever had a procedure to clear a blocked neck artery (a carotid endarterectomy)?
		No Yes
		If YES, when was it done?
		Within the past year 1 to 5 years ago More than 5 years ago
SECTION 3: MEDICATIONS
	14. Has your doctor prescribed medication for any of the following within the last year?
		Mini-stroke/TIA Symptoms Stroke Prevention Blood Clotting Problems High Cholesterol High Blood Pressure Atrial Fibrillation Other Heart Conditions
	15. Do you take blood pressure medication?
		No Yes
		If YES, do you take it regularly?
		Yes, I take it exactly as prescribed. Yes, but sometimes I forget it. No, my doctor prescribed it, but I don't take it.
	16. Has your doctor prescribed aspirin on a daily basis?
		No Yes
		How often do you take aspirin?
		Daily Occasionally Never
	17. Please mark any of the following which have been prescribed by your doctor:
		Coumadin™ or Warfarin Plavix™ or clopidogrel Aggrenox™ or dipyridamole-aspirin Statin Cholesterol-lowering medication
SECTION 4: STROKE KNOWLEDGE
	18. Where in the body does a stroke originate?
		Heart Arms and legs Brain
	19. A slight temporary numbness on the left side of your face could be a stroke.
		True False
	20. Stroke is the 3rd leading cause of death in the United States.
		True False
	21. You are at increased risk for stroke if:
		You have had a previous stroke or TIA (mini-stroke) You smoke cigarettes You are overweight or obese All of the above
	22. Stroke is a leading cause of adult disability.
		True False
	23. If you experience stroke signs or symptoms, what should you do?
		Discuss with family or friends Wait to get better Call your doctor immediately Call 911
I understand that this information will be reviewed by the survey sponsor, and
any areas that might benefit from extra attention will be communicated to me.
Thank you for completing this questionnaire.
National Stroke Association
9707 E. Easter Lane
Centennial, CO 80112
1-800-STROKES