Preventive Cardiac Health Screening
Know Me Form

iLiveConnect  ·  Powered by IHLD Clinical Expertise  ·  Dr. Rahul Chandola, Founder Chairman

This questionnaire is designed to assess your cardiovascular risk and tailor your monitoring programme. All information is strictly confidential and used solely for clinical purposes.

Section 1 — Personal Details
Section 2 — Physical Measurements
Section 3 — Lifestyle Habits
A. Smoking
B. Alcohol
C. Physical Activity
D. Diet & Nutrition
E. Sleep & Stress
Section 4 — Personal Medical History
QuestionYesNo
Have you ever been diagnosed with heart disease?
Have you ever had a heart attack?
Have you ever had a stroke or TIA (mini-stroke)?
Do you have high blood pressure (Hypertension)?
Do you have diabetes (Type 1 or Type 2)?
Do you have high cholesterol?
Do you have a thyroid condition?
Do you have kidney disease?
Have you had any cardiac procedure / surgery in the past?
Have you ever had an abnormal ECG or Echo report?
Have you ever experienced chest pain or tightness?
Do you experience shortness of breath on mild exertion?
Do you experience palpitations (rapid or irregular heartbeat)?
Have you ever fainted or felt dizzy without a clear reason?
Do you experience swelling in feet or ankles?
Section 5 — Current Medicines & Supplements

e.g. Aspirin, Warfarin, Clopidogrel

e.g. Omega-3, Vitamins, Protein

Section 6 — Family History
QuestionYesNo
Has any first-degree relative (parent, sibling) had heart disease?
Has any relative had a heart attack before age 55 (male) / 65 (female)?
Has any close relative had a sudden cardiac death?
Is there a family history of diabetes?
Is there a family history of high blood pressure?
Is there a family history of high cholesterol?
Is there a family history of stroke?
Section 7 — Current Symptoms Checklist

Please tick any symptoms experienced in the last 3 months:

Section 8 — Emergency Contact ★

During an emergency we must contact:

Section 9 — Shipping Details ★

Full address including PIN code

Secretary / PA as Point of Contact
Consent & Declaration

By submitting this form, you confirm: "I hereby confirm that all information provided above is true and accurate to the best of my knowledge. I consent to iLiveConnect using this information for clinical assessment, health monitoring, and necessary follow-up communication."

Your information is encrypted and stored securely. We will never share it with third parties.

✅ Thank you! Your Know Me Form has been submitted successfully. Our clinical team will review your details and be in touch shortly.
❌ Something went wrong. Please try again or contact us directly.