Annual Coronary Heart Disease Review

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

Please note – if you submit this request after 4pm on a working day, it will be opened when we re-open on the next working day. The practice is closed over the weekend.

Annual Coronary Heart Disease Review

Section

About You

eg. 1.75
eg. 60.6

Smoking

Smoking status: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

Activity Levels

Please indicate which option best describes your 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

Have you had any shortness of breath since your last review? *
Would you describe yourself as currently having issues with breathlessness? *
Do you currently have, or have you had since your last review, any swelling of your leg? *
In which part of your leg have you experienced swelling?
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) *
Do you have any concerns with your memory? *

Please book an appointment with your GP to discuss the issues you are having.

*