CDM - Atrial Fibrillation (AF)/ Chronic Heart Disease (CHD) - Clackmannan and Kincardine Medical Practice

If you have your own blood pressure monitor, what is your blood pressure reading?

If you are able to monitor this, what is your pulse rate?

Do you have palpatations (rapid or irregular heart beat)? *

Yes No

Height *

Weight *

Do you smoke? *

Yes No

If you do smoke, how many do you smoke per day?

How many units of alcohol do you drink per week? *

How much exercise do you take? *

Exercise one per week

Exercise twice per week

Exercise 3 or more times per week

No exercise

Have you experienced chest pain since your last review? *

Yes No

Do you have any new ankle swelling? *

Yes No

Are you breathless at night? *

Yes No

How do you rate this online form? *

Excellent

Good

Unsatisfactory

Please confirm you will contact the practice to make an appointment for annual blood tests, and if you do not have a blood pressure machine, a blood pressure check. *

Yes

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 *

I consent to the practice collecting and storing my data from this form.

CDM - Atrial Fibrillation (AF)/ Chronic Heart Disease (CHD)

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