Annual Heart Disease Review

Section

Have you received a letter advising you to complete this review?

Yes

No

Please specify requester and date of letter:

Please use date format DD/MM/YYYY.

Patient Status

Height:

Weight:

Alcohol Consumption:

Units per week

Do you smoke?

Yes

No

How many do you smoke in a day?

Would you like to be referred to a smoking cessation adviser?

Yes

No

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

Are you an ex smoker?

Yes

No

What date did you give up smoking?

Please use date format DD/MM/YYYY.

How many did you smoke in a day?

Activity levels:

Does not regularly exercise

Enjoys moderate exercise

Exercises regularly

Your Blood Pressure

Please provide a minimum of one blood pressure reading, up to a maximum of seven.

Day 1

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 2

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 3

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 4

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 5

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 6

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Day 7

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Evening Measurement

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Additional Questions

Do you suffer from any shortness of breath?

Yes

No

Do you have any leg or ankle swelling?

Yes

No

Do you have any leg wounds?

Yes

No

Do you have any concerns with your memory?

Yes

No

When are you available to take a call in the next few weeks?

Text/Email Consent

The practice can send you a text message or email with your appointment time and appointment reminder. *

I agree to the practice sending me text messages and emails including appointment times and appointment reminders

I do not agree to the practice sending me text messages and emails including appointment times and appointment reminders

Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Please select one of the options below:

Consent: *

Express consent for medication, allergies and adverse reactions only.

Express consent for medication, allergies, adverse reactions and additional information - further medical information includes your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

Express dissent for Summary Care Record (opt out) - you do not want any information shared with other healthcare professionals involved in your care.

Are you sure? If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.

*

I confirm that the information provided is accurate to the best of my knowledge

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