How old are you?
Under 55
55-65
66-75
78-85
86 or older

What is your race?
White
Black
Hispanic
Other

Do you have diabetes?
Yes
No

Have you had a previous stroke?
Yes
No

Do you have a history of atrial fibrillation; a rapid irregular heartbeat?
Yes
No
Don't know

Have you had a transient ischemic attack, also known as a ministroke or TIA?
Yes
No

What's your smoking history?
Never smoked
Stopped within the past 3 years
Smoke regularly

What is your systolic blood pressure; the top, high number?
Less than 120
121 to 139
140 to 159
160 or higher
Don't know

Do you have a first-degree relative (parent or sibling) who had a stroke?
Yes
No

Do you have a high red blood cell count?
Yes
No
Don't know

Do you drink alcohol?
No
One drink per day
Two drinks per day
Three or more drinks per day
I often binge drink

Do you use cocaine?
Yes
No

What's your body weight?
Underweight
Average
Overweight
Obese

How active are you?
Inactive
Moderately active
Very active