This page displays the questions presented as part of the exam scheduling process. Do not enter or send personal health information through this page.
During scheduling, your responses will be provided to the healthcare professional reviewing your heart-sound recordings. They will not be reviewed or interpreted by the Medaica Technician during your telehealth heart examination.
Please answer based on what you have personally experienced. Select “Not sure” when appropriate.
1. Height
What is your height?
_____ ft _____ in
2. Weight
What is your weight?
_____ lbs
3. Race and Ethnicity
How do you describe your race and/or ethnicity? Select all that apply.
☐ American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Hispanic or Latino
☐ Middle Eastern or North African
☐ Native Hawaiian or Other Pacific Islander
☐ White
☐ Another race or ethnicity: __________
☐ Prefer not to answer
4. Heart Rhythm
Have you noticed an irregular, racing, fluttering, or skipped heartbeat?
☐ No ☐ Yes ☐ Not sure
5. Chest Discomfort
Have you experienced chest pain, pressure, or tightness?
☐ No ☐ Yes ☐ Not sure
6. Shortness of Breath
Have you experienced unexplained shortness of breath?
☐ No ☐ Yes ☐ Not sure
7. Fatigue or Reduced Activity
Have you recently become more tired or less able to perform your normal activities?
☐ No ☐ Yes ☐ Not sure
8. Dizziness or Fainting
Have you experienced unexplained dizziness, near-fainting, or fainting?
☐ No ☐ Yes ☐ Not sure
9. Swelling
Have you experienced unexplained swelling in your feet, ankles, or lower legs?
☐ No ☐ Yes ☐ Not sure
10. Heart Conditions
Have you ever been told by a healthcare professional that you have a heart murmur, heart valve problem, abnormal heart rhythm, heart failure, or another heart condition?
☐ No ☐ Yes ☐ Not sure
11. High Blood Pressure
Have you ever been told by a healthcare professional that you have high blood pressure (hypertension)?
☐ No ☐ Yes ☐ Not sure
12. Family History
Do you have a family history of heart disease?
☐ No ☐ Yes ☐ Not sure
Important
This questionnaire and the Medaica At-Home Heart Exam are not intended for medical emergencies. If you are currently experiencing a medical emergency, call 911 or local emergency services immediately.