Annual Heart Disease Review

If you have been advised by the surgery to complete an annual heart disease review, please use this form.

Annual Heart Disease Review

Annual Heart Disease Review

Section

Have you received a letter advising you to complete this review?
Please use date format DD/MM/YYYY.

Patient Status

Units per week
Do you smoke?
Would you like to be referred to a smoking cessation adviser?
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?
Please use date format DD/MM/YYYY.
Activity levels:

Your Blood Pressure

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

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

/
Evening Measurement
/

Additional Questions

Do you suffer from any shortness of breath?
Do you have any leg or ankle swelling?
Do you have any leg wounds?
Do you have any concerns with your memory?
*