Heart Failure Review

Please only complete the following questionnaire if requested by your GP practice as part of your cardiovascular review.

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

Please see the following for further information on heart failure that you may find useful:

Heart Failure Review
Are you experiencing chest pain? *
Are you experiencing severe shortness of breath? *

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

Section

How much effect is your heart failure having on your daily activities? *
Have you had any shortness of breath? *
Do you feel breathless when you lie flat? *
Do you wake up in the night gasping for breath? *
Do you have any leg swelling? *
Please specify:
How is your mood? *
How is your memory? *
If any of the problems are new or getting considerably worse, please telephone the surgery for further assessment. In an emergency, you should call 999.

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. Then sit in a chair comfortably upright with your arm supported on the table beside you, put 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 with your pulse rate and any comments and repeat that evening 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 and divide by the number of blood pressures done, then repeat with the bottom diastolic blood pressures.

mmHg
/
mmHg
bpm
The rhythm of my pulse is:

About You

eg. 1.75
eg. 60.6

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

Smoking

Smoking status: *
Do you use an e-cigarette? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

*