Cardiovascular Health Check

Physical Measurements

If you would like help with your diet, then please look at the following websites:

https://www.nhs.uk/live-well/eat-well/food-guidelines-and-food-labels/the-eatwell-guide/

https://www.nhsinform.scot/healthy-living/12-week-weight-management-programme/

Height (approximate if not known) *

Blood Pressure - if you do not have your own blood pressure monitor at home or are unable to do your own reading, please let reception know when booking in for a blood test.

Waist circumference (please indicate whether inches or cm) Make sure you use a tape measure and use your fingers to feel for your bottom rib and the top of your hip bone and measure around your body directly between these two points. Don't have measuring tape? Use a piece of string to wrap around your middle and then measure this against a ruler or a metal tape measure. *

Weight (approximate if not known) *

Alcohol Intake

Bottle of beer/lager/cider 330ml (5%) = 1.7units; Can (5%) 440ml = 2.2units; Pint(5%) = 2.8units;4% beer/cider/larger=2.3 units.

Wine: bottle (13%) 9.8units;250ml (13%) = 3.3 units;175ml (13%) = 2.3mls; Prosecco/wine 250ml11% = 2.8 units; 175mls (11%0 = 1.9 units

Clear spirits 37.5% 25ml (single) = 0.9 units; double 50ml 37.5% (double) = 1.9 units.

Dark spirits single 25ml (40%) = 1 unit; Double 50ml 40% = 2 units.

Help with reducing/stopping alcohol phone 07843339958

Smoking Status

Smoking cessation available from your local pharmacy or NHS quit your way smoking on 0131 537 9914.

Family history of coronary heart disease (heart attack, angina) or stroke in a parent or sibling before the age of 60. *

No known family history

yes

If yes - Relationship to you

Age at diagnosis (if known)

Family History of Diabetes in a parent, sibling or child *

Yes No

If yes relationship to you

Has a doctor ever told you that you have high blood pressure, or given you medication for it? *

Yes No

Consent

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.

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Cardiovascular Health Check

Further Information