Heart Assessment

Please complete this Heart Assessment form if instructed by your GP.

Heart Assessment Form

Patient Details

Please use date format DD/MM/YYYY
Any responses will be sent to this email address.

Heart Assessment

Do you check your own blood pressure at home?
Please give average reading:
Is there any of your regular medication which you are not taking regularly at present?
How often do you have a drink containing alcohol 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?
Would you like advice from the smoking cessation team to help you stop?
Do you get swelling in your ankles?
How many pillows do you sleep on at night?
Do you get short of breath at night, so you have to sit up to catch your breath?
Which description fits your symptoms best?
Are you happy with your current symptoms related to your heart, or do you feel you need a further review at this time?
Flu injections are recommended for everone 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.