Female, first degree relative before the age of 65 Age / Gender Index Smoking status 0 Male / female 30 years of age 0 None 1 30 40 years of age 1 Pipe – 2 Female 40 - 50 years of age 2 1 10 cigarettes daily – 3 Male 40 50 of age 3 11 20 cigarettes daily – – 3 Female 50 60 of age 4 21 30 cigarettes daily – – 4 Male 50 60 of age 5 31 40 cigarettes daily – – 4 Male / female 60+ years of age 6 41 60 cigarettes – 8 + 60 cigarettes daily State how long you have smoked for: Years______________months______ ______ How would you describe your bodyweight? Total Cholesterol 0 Ideal weight 0 < 5 mmol / L 2 0 5kg overweight 1 5.0 5.2 mmol / L – – 4 6 10kg overweight 3 5.3 5.9 mmol / L – – 6 11 15kg overweight 5 6.0 6.2 mmol / L – – 8 + 15kg overweight 6 6.3 6.9 mmol / L – 10 Underweight 7 7.0 7.5 mmol / L – 8 > 7.5 mmol / L Not sure Systolic Blood Pressure Diastolic Blood Pressure 0 < 130 mmHg 0 < 80 mmHg 1 130 140 mmHg 1 81-90 mmHg – 2 141 150 mmHg 2 91 100 mmHg – – 3 151- 160 mmHg 3 101 110 mmHg – 4 > 160 mmHg 4 > 110 mmHg Not sure Not sure Diabetes Occupational activity level 0 None 1 Intense physical labour 1 Type 11 (non-insulin dependent) 2 Moderate (walk often etc.) 2 Type 1 (insulin dependent) 3 Sedentary Work Stress Tension 0 No stress, very relaxed 1 Moderate work stress and relaxed personality 2 High work stress but cope well 3 Very high work stress and tense personality
Female, first degree relative before the age of 65 Age / Gender Index Smoking status 0 Male / female 30 years of age 0 None 1 30 – 40 years of age 1 Pipe 2 Female 40 - 50 years of age 2 1 – 10 cigarettes daily 3 Male 40 – 50 of age 3 11 – 20 cigarettes daily 3 Female 50 – 60 of age 4 21 – 30 cigarettes daily 4 Male 50 – 60 of age 5 31 – 40 cigarettes daily 4 Male / female 60+ years of age 6 41 – 60 cigarettes 8 + 60 cigarettes daily State how long you have smoked for: Years______________months______ ______ How would you describe your bodyweight? Total Cholesterol 0 Ideal weight 0 < 5 mmol / L 2 0 – 5kg overweight 1 5.0 – 5.2 mmol / L 4 6 – 10kg overweight 3 5.3 – 5.9 mmol / L 6 11 – 15kg overweight 5 6.0 – 6.2 mmol / L 8 + 15kg overweight 6 6.3 – 6.9 mmol / L 10 Underweight 7 7.0 – 7.5 mmol / L 8 > 7.5 mmol / L Not sure Systolic Blood Pressure Diastolic Blood Pressure 0 < 130 mmHg 0 < 80 mmHg 1 130 – 140 mmHg 1 81-90 mmHg 2 141 – 150 mmHg 2 91 – 100 mmHg 3 151- 160 mmHg 3 101 – 110 mmHg 4 > 160 mmHg 4 > 110 mmHg Not sure Not sure Diabetes Occupational activity level 0 None 1 Intense physical labour 1 Type 11 (non-insulin dependent) 2 Moderate (walk often etc.) 2 Type 1 (insulin dependent) 3 Sedentary Work Stress Tension 0 No stress, very relaxed 1 Moderate work stress and relaxed personality 2 High work stress but cope well 3 Very high work stress and tense personality