Cardiovascular Disease Review

If you have been advised by the surgery to submit an annual review of your cardiovascular symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Further Information:

Cardiovascular Disease Review

Cardiovascular Disease Review

Have you received a letter, text message or verbal invitation to complete this assessment?

Your Health Information

Weight unit:
Waist Unit:
Smoking status

For more information and help to give up smoking, please visit: www.quitwithhelp.co.uk


This is one unit of alcohol:

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

How often do you have a drink contatining alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *
Have you needed to use your GTN spray?
Are you taking any over the counter medication such as vitamin supplements or pain relief?

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
/
*