Heart Disease Support Programme Heart Disease Support Programme Name Name First Name First Name Last Name Last Name Email Phone Date of Birth Gender MaleFemaleNon-BinaryPrefer Not to Say Type of Heart Disease * High Blood Pressure (Hypertension) High Cholesterol Coronary Artery Disease Heart Failure Arrhythmia (Irregular Heartbeat) Other Other Are you currently taking any heart-related medications? Yes No Recent Blood Pressure Reading (if available) Recent Cholesterol Levels (if available) Do you have a family history of heart disease? Yes No Current Activity Level Sedentary (Little to No Exercise)Lightly Active (1-2 Workouts Per Week)Moderately Active (3-4 Workouts Per Week)Very Active (5+ Workouts Per Week) Current Eating Habits Low-Sodium Diet High-Processed/Fast Food Intake High Sugar Consumption Balanced Diet with Whole Foods Vegetarian/Vegan Other Other Biggest Challenges in Heart Health Managing Blood Pressure Reducing Cholesterol Avoiding Processed Foods Exercising Regularly Managing Stress Other Other Any Food Allergies or Restrictions? Dairy-Free Gluten-Free Nut Allergy Low-Sodium Only None Other Other Aid My Heart Meal Plan Preferences Low-Sodium & Low-Cholesterol Meals Quick & Easy Recipes Plant-Based Options Heart-Healthy Mediterranean Diet Family-Friendly Plans Exercise Preferences Walking & Light Cardio Strength Training Yoga & Mindfulness Exercises Post Surgery Rehabilitation Do you experience stress frequently? Yes No How many hours of sleep do you get per night? Less than 55-67-88+ Package Selection * Basic Heart-Healthy Meal Plan 3000Advanced Plan with Coaching 10000Premium Plan with Weekly Adjustments 15000 Payment Terms and Condition I confirm that the information provided is accurate, and I agree to the terms of the Heart Disease Support Programme. If you are human, leave this field blank.
