Healthy Heart Questionnaire

Your Healthy Heart review is now due. It may not be necessary for you to attend the surgery for this review to be carried out. If requested to do so please complete the following questionnaire and return to the surgery.


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.

Healthy Heart Questionnaire

Blood Pressure:

Please complete this section if you have a blood pressure monitor at home. Otherwise, please leave this blank and skip to the next section.

Please take two readings at least 1 minute apart and record the second reading.

Lifestyle- Alcohol
Further Questions
The Next Step

When you are happy with all of your above answers, please return this questionnaire to your GP Practice. Your completed Healthy Heart Questionnaire will now be reviewed by a Health Care Professional, and we will be in touch again once this has taken place.

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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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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