Heart Check Questionnaire

Forename*
Surname*
Date of Birth*
MM slash DD slash YYYY
NHS Number (if known)
Email*
Home Phone*
Mobile*
Height*
Weight*
Do you have any concerns about your HEART health? If so, please write details below:
Do you have any shortness of breath or chest pain? If so write details below:
Do you have any pain in your legs when you walk which settles with rest? If so, please write details below:
Check all the relevant symptoms
- Indigestion (a possible side effect of Aspirin)
- Swollen ankles, headaches, flushing (a possible side effect of Amlodipine or Nifedipine)
- Dry Cough (a possible side effect of Ramipril, Captopril, Lisinopril or Enalapril)
If you have a GTN spray, how often do you use it?
Do you always remember to take your medication?
- Yes
- No
Are you buying your own Aspirin?
- Yes
- No
Smoking Status
- Never smoked
- Ex-smoker
- Current smoker
If you are a current smoker, what do you smoke?
- Cigarettes
- Cigar
- Pipe
- E-cigarette
How much do you currently smoke per day?
Do you require help to give up smoking?
- Yes
- No
How many units of alcohol do you consume in a week? (see table below)*

Type of drink	Number of units
Single small shot of spirits (25ml, ABV 40%)	1 unit
Gin, rum, vodka, whisky, tequila, Sambuca. Large (35ml)	1.4 units
Alcopop (275ml, ABV 5.5%)	1.5 units
Small glass of red/white/rosé wine(125ml, ABV 12%)	1.5 units
Bottle of lager/beer/cider (330ml, ABV 5%)	1.7 units
Can of lager/beer/cider (440ml, ABV 5.5%)	2 units
Pint of lower-strength lager/beer/cider (ABV 3.6%)	2 units
Standard glass of red/white/rosé wine (175ml, ABV 12%)	2.1 units
Pint of higher-strength lager/beer/cider (ABV 5.2%)	3 units
Large glass of red/white/rosé wine (250ml, ABV 12%)	3 units

For patients who suffer from coronary heart disease we recommend a maximum of 21 units a week for men and 14 for women, and no binge drinking.