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Coronary Heart Disease Review Form

Forth Medical Group > Your Record > Health Review Forms > Coronary Heart Disease Review Form
Coronary Heart Disease Review
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Please use format day/month/year e.g. 12/05/1979

CHD Review

Note: This form is for routine reviews and not for urgent requests. If you currently have chest pains/tightness, palpitations or new shortness of breath you may need urgent attention and should dial 999 or contact the practice directly for advice. Do not use this form for urgent purposes.

Have you had chest pains or chest tightness in the past 4 weeks? *
Have you had palpitations in the past 4 weeks? *
Have you had new shortness of breath at rest or exertion in the past 4 weeks? *
Have you had swelling of feet or ankles in the past 4 weeks? *
Have you had to use a GTN spray (spray under tongue) in the last 12 months? *
Do you have any specific issues with your heart disease which you would like to discuss further? *

Height, Weight and BMI

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Lifestyle

1 unit = 1 small glass of wine, half pint of beer/lager, single measure of spirit/whisky/vodka etc
Do you smoke? *
How often do you exercise per week (at least 30 minutes) *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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