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South Coast Medical Group Promoting health in the local community

Heart failure review

Heart Failure Review

Section

Which surgery are you registered with? *

Crescent Providence Surgery – 12-14 Walpole Road, Boscombe, BH1 4HA

Marine and Oakridge Surgery – 29 Belle Vue Road, Southbourne, BH6 3DB

Denmark Road Medical Centre – 37 Denmark Road, Winton, BH9 1PB

Woodlea House Surgery – 2A Bradpole Road, Castle Lane West, BH8 9NX

The Grove Surgery – Fairmile Road, Christchurch, BH23 2FQ

Address:

Height:

Weight:

Blood Pressure

Systolic (Higher)

Diastolic (Lower)

Pulse

How would you best describe your symptoms?

I have no limitations on my physical activity

I have mild symptoms with physical activity but comfortable at rest

I have moderate symptoms with physical activity but comfortable at rest

I have breathlessness on all physical activity and at rest

Alcohol

This is one unit of alcohol:

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

How many units do you consume each week?

Smoking

What is your daily consumption?

Never smoked

Ex-smoker

Trivial smoker (less than 1 a day)

Light smoker (1-9 a day)

Moderate smoker (10-19 a day)

Heavy smoker (20-39 a day)

Very heavy smoker (40+ a day)

Use an electronic cigarette or a vape

Would you like advice and support regarding lifestyle (smoking and alcohol) or weight management?

Yes

If you are human, leave this field blank.

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