2018 My Heart Challenge Application

Participant Information
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Please use this format: Month/Day/Year
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Health Information
Do you have one or more of the following cardiac risk factors (NOTE: Answering YES or NO does not eliminate you from eligibility): High Cholesterol; High blood pressure; High blood glucose; Overweight


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If you do smoke, do you commit to starting a smoking cessation program as part of your participation in the My Heart Challenge?


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If you do have a history of heart disease, who has it?




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Acknowledgements
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