Heart Assessment

Do you check your own blood pressure at home?

Yes

No

Please give average reading:

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Please tell us if you have any problems related to any of your regular medication?

Is there any of your regular medication which you are not taking regularly at present?

Yes

No

Why?

How often do you have a drink containing alcohol per week?

Never

1 time per week

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking?

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

Do you smoke?

Yes

No

Would you like advice from the smoking cessation team to help you stop?

Yes

No

How much do you weigh? (please state whether lbs or kgs)

How much has your weight gone up or down over the last month? If it is changing, can you give reasons for the change?

Do you get swelling in your ankles?

Yes

No

Please describe how much:

How many pillows do you sleep on at night?

0

1

2

3+

Do you get short of breath at night, so you have to sit up to catch your breath?

Yes

No

Which description fits your symptoms best?

I am not bothered by any restriction or limitation in how I can exercise. I do not get fatigue, palpitations, shortness of breath or chest pain on normal activity and have no limitation or normal physical activity

I have a slight restriction in my physical activity, so I am a bit short of breath, fatigues or get palpitations on ordinary physical activity

I have marked limitation on physical activity. I am OK when sitting down but if I try to do small things I get short of breath, fatigues or get palpitations

I get discomfort on any physical activity and feel some shortness of breath, palpitations or fatigue even when sitting still

Please describe how much activity you have to do on the flat before you get a problem. Describe what symptoms you get.

Please describe how much activity you have to do going up hill or up stairs before you get a problem. Describe what symptoms you get.

Are you happy with your current symptoms related to your heart, or do you feel you need a further review at this time?

Happy with symptoms

Further review needed

Flu injections are recommended for everyone aged 50 and over and all those who have a record of cardiovascular disease such as angina, heart attacks, strokes, and diabetes. Please contact the surgery for an appointment if you have not had a flu injection this Winter and would like one.

We normally like patients with cardiovascular disease to have a blood test at least every 12 months (depending on the problem and the medication they take) . Normally we suggest you arrange this around your birthday. However, with the high levels of the current Covid Pandemic, we are suggesting that most patients defer routine blood tests at present if they are not having problems, and if medication is not changing.

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