Healthy Heart Questionnaire

Review Information:

Please only complete the following questionnaire if requested by your surgery as part of your routine Healthy Heart Review. 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.

Home Blood Pressure Monitoring (HBPM) is increasingly used by GP's as a safe and accurate way to manage your blood pressure. Many of our patients already have a monitor at home, and we would encourage all of our Healthy Heart Patients to home monitor. Monitors for home use should be clinically validated and an up-to-date list of such devices is available at www.bhsoc.org, or can be purchased from your local pharmacy.

We would suggest that you monitor your blood pressure twice weekly, and submit average readings to the surgery every six months. If your blood pressure is persistently elevated over 3 or more readings, please contact the surgery to arrange a BP check with our Health Care Assistant, and bring your home monitor along to this appointment.

If your results are within target range the healthcare professional will add them to your medical record once they have reviewed them, and let you know if any follow-up or blood tests are required. If your average blood pressure reading is outside the normal range we will contact you to arrange an appointment with our Healthcare Assistant. Please bring your monitor along to this appointment.

Please select the practice location most relevant to this Online Form submission:

Healthy Heart Questionnaire

Name

Date of BirthPlease enter Date of Birth as DD/MM/YYYY

Home Telephone

Mobile Telephone

Email address

Home Blood Pressure Recordings:

Please complete this section if you have a blood pressure monitor at home. Otherwise, please leave this blank and skip to the next section. In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes, sit in a chair comfortably upright with your arm supported on a table beside you, both feet on the ground. Put the cuff on you arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart. Press the on/start button on the BP monitor, take two readings at least 1 minute apart. Record the readings with your pulse rate and any comments, repeat that evening and for a total of 7 days using alternate arms. Calculate your average blood pressure by ignoring the first day of readings (as this was when you were getting used to the monitor) and take an average of the remaining readings. Add up all the top systolic blood pressures, divide by the number of blood pressures done. Repeat with the bottom diastolic readings.

My average home SYSTOLIC blood pressure recording is:

My average home DIASTOLIC blood pressure recording is:

My pulse rate per minute is:

The rhythm of my pulse is:

Regular

Irregular

My current weight is:

My current height is:

Lifestyle- Alcohol

1 - How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-4 times per week

4 times or more per week

2 -How many units of alcohol do you drink on a typical day drinking? Please see: https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator

1-2

3-4

5-6

7-9

10+

3 - 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?

Never

Less than Monthly

Monthly

Weekly

Daily or almost daily

Think you might be drinking too much? We know it can be hard to keep track of how much you are drinking. The latest advice for adults- for both men and women- is that you should drink no more than 14 units a week. If you would like 1:1 support to reduce your alcohol consumption contact OneSmallStep by telephoning 01392 908 139 or via their website https://www.onesmallstep.org.uk

Lifestyle-Smoking

1. Do you smoke?

Never

Ex-smoker

Trivial smoker(less than 1 cigarette per day)

Light smoker(1-9 cigarettes per day)

Moderate smoker(10-19 cigarettes per day)

Heavy smoker(20-39 cigarettes per day)

Very heavy smoker(40 or more cigarettes per day)

2. Do you use an e-cigarette?

Ex-user

Yes

3. If you smoke, would you like help to quit smoking? For further information, please see: www.nhs.uk/smokefree or www.onesmallstep. OneSmallStep is a FREE health service to support the health and wellbeing of Devon residents. They offer support alongside Nicotine Replacement Therapy (NRT) and can be contacted via their website or by phoning 01392 908 139.

Yes

Further Questions

Do you have any new symptoms relating to your Healthy Heart Review/Medication, that you haven't already discussed with a health care professional, that you would like to raise at this time?

Please see the following links for further information that you may find useful:

NHS- https://www.nhs.uk/conditions/cardiovascular-disease

Patient.Info- https://patient.info/health/cardiovascular-disease-atheroma

British Heart Foundation-https://www.bhf.org.uk

When you are happy with all your above answers, please click "Submit" below and the questionnaire will be automatically sent to your GP practice. Depending upon your answers and your other medical conditions , you will be contacted if you need to be seen in clinic for a further assessment. Should your symptoms change, please seek medical advice and book an appointment if required.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Riverside Surgery • Le Molay-Littry Way, Bovey Tracey, Devon, TQ13 9QP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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