Cardiovascular Review

Please complete the following questions to allow your health care professional to assess your cardiovascular health.

This questionnaire is for a routine review of your symptoms. If you are experiencing chest pain, severe shortness of breath or other concerning symptoms, please follow your care plan (if you have one) or ring your GP or 999 immediately

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Your Cardiovascular Health

Please telephone the surgery immediately (or phone 999 if necessary) for further assessment
If severe, please telephone the surgery immediately (or phone 999 if necessary) for further assessment
Please telephone the surgery for further assessment if this swelling is new or getting considerably worse

Home Blood Pressure Readings

Please complete this section if you have a blood pressure monitor at home.

1. In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes.
2. Then sit in a chair comfortably upright with your arm supported on a table beside you, with both feet on the ground.
3. Put the cuff on your upper arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart.
4. Press the on/start button on the BP monitor and take two readings at least 1 minute apart.
5. Record the readings below with your pulse rate and any comments.
6. Repeat that evening & for a total of 4 days using alternate arms.

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
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Evening Measurement
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Day 4

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

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Evening Measurement
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