Check all that apply.

Self    Family    Medical History

☐       ☐             Previous Stroke
☐       ☐             Previous Mini-Stroke / TIA
☐       ☐             Carotid Artery Disease
☐       ☐             High Blood Pressure
☐       ☐             Previous Heart Attack
☐       ☐             Heart Disease
☐       ☐             Atrial Fibrillation
☐       ☐             Heart Surgery
☐       ☐             Diabetes
☐       ☐             High Blood Cholesterol (current or past)
☐       ☐             Current Smoker: How much? ___ packs per day
☐       ☐             Former Smoker
☐       ☐             Alcohol Consumption: How much? ___ drinks per day

If you checked any of these, you have risk factors for stroke. Call your doctor to discuss your risk of stroke. To make an appointment, call 1.877.UT.CARES (1.877.882.2737).

Learn about stroke and its risk factors, warning signs and treatments.