Annual coronary heart disease review

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

About You

Height (in Meters): Required

eg. 1.75

Weight (in Kilograms): Required

eg. 60.6

BMI:

Alcohol Consumption (units per week):

Smoking

Smoking status: Required

Smoker

Never smoked

Ex smoker

Smoker

How many cigarettes do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? Required

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking? Required

Yes

No

Ex Smoker

Rollups – How many grams of tobacco did you smoke per week? Required

Pipe – How many grams of tobacco did you smoke per week? Required

When did you give up smoking? Required

Activity Levels

Please indicate which option best describes your activity levels:

Gets no exercise

Gets little 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

Have you had any shortness of breath since your last review? Required

Yes, I have had problems with breathlessness

No, I have not had problems with breathlessness

Would you describe yourself as currently having issues with breathlessness? Required

Yes

No

Do you currently have, or have you had since your last review, any swelling of your leg? Required

Yes

No

Do you currently have, or have you had since your last review, any leg wounds that the practice is unaware of? (eg. ulcers, weeping or open sores) Required

Yes

No

Do you have any concerns with your memory? Required

Yes

No

Required

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

Required

I confirm that I am a patient at Grovelands Medical Centre, London.

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About You

Smoking

Smoker

Ex Smoker

Activity Levels

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure

Additional Questions