Cardiovascular Disease Annual Review

If you have been advised by the surgery to submit a review of your Cardiovascular Disease, please use this form.

Blood Pressure

If you have access to a blood pressure machine you will be required to submit 6 days worth of readings.

Each day you will be required to provide the below readings:

  • AM – 1st Blood Pressure (mm/Hg)
  • AM – 1st Pulse Rate (beats/ minute)
  • AM – 2nd Blood Pressure (mm/Hg)
  • AM – 2nd Pulse Rate (beats/ minute)
  • PM – 1st Blood Pressure (mm/Hg)
  • PM – 1st Pulse Rate (beats/ minute)
  • PM – 2nd Blood Pressure (mm/Hg)
  • PM – 2nd Pulse Rate (beats/ minute)
Cardiovascular Disease Annual Review

You are due for a review because you have a diagnosis of one or more of the following conditions:

  • Ischaemic Heart Disease (Angina/ Previous Heart Attack etc.)
  • Peripheral Vascular Disease (Poor Circulation)
  • A previous Stroke or TIA (Mini Stroke)
  • Atrial Fibrillation or Atrial Flutter (Irregular Heart Beat)

Please answer the following questions, for the condition(s) relevant to you.

The answers you give will help us to determine the most appropriate way to carry out your review and to identify patients who need an urgent review.

Understanding Your Condition(s)

Do you feel that you understand your cardiovascular condition and treatment? *
Do you consent to us sending you information about your condition by SMS messaging to your mobile phone if appropriate? *

Ischaemic Heart Disease

I understand that if I get central chest pain that lasts for more than 15 minutes, and is not relieved by my GTN spray, I should ring 999 and ask for an ambulance.

Peripheral Vascular Disease

I understand that the advice about exercise for patients with PVD is to exercise/walk regularly, if they are able to do so.

Stroke/TIA

I understand that if I think I am having a stroke or TIA, I should ring 999 and ask for an ambulance.

Medication and Symptom Review

Are you having any problems with your medication? *
Are you getting any chest pains or angina? *
Do you ever get chest pains/ angina when you are at rest? *

If you are getting chest pains/angina at rest, please phone the surgery to request a same-day GP call-back.

Are you getting more short of breath or are your ankles becoming more swollen? *
Are you getting dizzy spells or have had any blackouts/falls recently? *
Are you getting any palpitations (episodes of your heart racing)? *
Do you have any new foot ulceration? *

If you have new foot ulceration, please phone the surgery to request a same day Nurse Practitioner call back.

Smoking

Do you currently smoke? *
Do you wish to be sent details of how to access support to help you quit? *

Flu Vaccination

Have you had your annual flu vaccination this year? *
Would you like us to arrange for you to have a flu vaccine? *

Weight

Blood Pressure

Do you have access to a home blood pressure monitor? *
If yes, or you are able to purchase or borrow one, please complete the blood pressure diary below.

Home Blood Pressure Diary

Patient Instructions

  • In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes.
  • Then sit in a chair comfortably upright with your arm supported on a table beside you, with both feet on the ground.
  • 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.
  • Press the on/start button on the BP monitor and take two readings at least 1 minute apart.
  • Record the readings below with your pulse rate and any comments.
  • Repeat that evening & for a total of 6 days using alternate arms. Then return this diary (& BP monitor if borrowed) to the surgery.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Day 1

Please use date format: DD/MM/YYYY

Day 2

Please use date format: DD/MM/YYYY

Day 3

Please use date format: DD/MM/YYYY

Day 4

Please use date format: DD/MM/YYYY

Day 5

Please use date format: DD/MM/YYYY

Day 6

Please use date format: DD/MM/YYYY