Stroke / TIA Questionnaire

If you have been advised by the surgery to do so, please submit this form.

If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Stroke / TIA Questionnaire

Stroke / TIA Questionnaire

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

Smoking

Smoking status *
Would you like help to give up smoking?

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

Your Health Information

Have you had any overnight hospital admissions relating to your stroke / TIA in the past 12 months? *
Are you able to exercise? *
Has this changed since your last review?
Please tell us about your waking ability: *
With regards to self care, please choose an option: *
Do you or your relatives have any concerns about your memory? *
Do you or your relatives have any concerns about your mood? *
Do you have any difficulties talking? *
Do you have any difficulties swallowing? *
Do you have any difficulties with passing urine (going for a wee)? *
Do you have any difficulties with opening your bowels (going for a poo)? *

Your Blood Pressure

Please provide a minimum of one blood pressure reading, up to a maximum of seven.

If you do not have access to a home blood pressure device, please visit the practice and use the machine in our waiting area and then submit this form.

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
/

Height unit:
Weight unit:

E.g. Monday AM/PM, Tuesday AM/PM
*