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Personal Cardiovascular Risk Assessment Tracker

Monitor Your Heart Health Progress

Cardiology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Risk Factor Tracking

Blood Pressure Readings

Date Systolic Diastolic Notes

Cholesterol Levels

Date Total LDL HDL Triglycerides

Other Risk Factors

Body Mass Index (BMI)

  • Height: _______
  • Weight: _______
  • Current BMI: _______
  • Target BMI: _______

Lifestyle Factors

  • Smoking Status: □ Never □ Former □ Current
  • Physical Activity (mins/week): _______
  • Alcohol consumption (drinks/week): _______

Risk Score Calculation

  • Framingham Risk Score: _______
  • ASCVD Risk Score: _______

Goals and Interventions

  1. Blood Pressure Target: _______
  2. LDL Cholesterol Target: _______
  3. Exercise Goal: _______
  4. Weight Goal: _______

Follow-up Appointments

Date Provider Notes

Medications

Medication Dose Frequency Start Date

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