Heart Disease Review - Howe of Fife Medical Practice LLP

Do you experience any chest pain or discomfort, particularly with physical activity? *

Yes No

If yes, does the pain spread to your jaw, neck, back or arms?

Yes

No

Do you have difficulty breathing *

Yes No

If yes, when does this happen?

When I am doing strenuous exercise

When I am walking faster than usual on level ground or walking up a slight hill

When I am walking at a slow pace on level ground

I am only able to walk short distances on level ground

I am unable to leave the house due to breathlessness

Do you feel dizzy or lightheaded? *

Yes No

Have you ever fainted? *

Yes No

Have you noticed a fluttering sensation or skipping sensation in your heartbeat? *

Yes No

Do you have any unexplained nausea or indigestion? *

Yes No

Do you experience cold sweats? *

Yes No

Do you have swelling in your ankles or feet? *

Yes No

Have you needed to use your GTN spray in the past year? *

Yes

No

I don't have a GTN spray

If yes, how often have you had to use your GTN spray

Do you wish to have a review with one of the doctors or nurses at the practice regarding your heart disease? *

Yes No

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.

Howe of Fife Heart Disease Review

Howe of Fife Heart Disease Review

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Howe of Fife Heart Disease Review

Howe of Fife Heart Disease Review

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