Stroke / TIA review

Have you received a letter, text message or verbal invitation to complete this assessment? *

Yes

No

Smoking and Vaping

Smoking/vaping status: *

Current smoker/vaper

Never smoked/vaped

Ex-smoker/vaper

How many cigarettes do you smoke per day, how often do you vape per day and at what nicotine strength or how much tobacco in grams do you use per week?

Would you like help to give up smoking/vaping?

Yes

No

For more information and help to give up smoking, please visit: www.quitwithhelp.co.uk

How many cigarettes did you smoke per day, how often did you vape per day and at what nicotine strength or how much tobacco in grams did you use per week?

When did you give up smoking/vaping?

Your Health Information

Have you had any overnight hospital admissions relating to your stroke / TIA in the past 12 months? *

Yes

No

In which months were you admitted to hospital?

Are you able to exercise? *

Yes

No

What limits your exercise?

What exercise do you do?

Has this changed since your last review?

Yes

No

Please tell us about your mobility: *

Walks unaided

Walks with walking aid

Walks with another person

Unable to walk, uses a wheelchair

With regards to self care, please choose an option: *

I am independent

I have carers

How often do you have carers?

Do you or your relatives have any concerns about your memory? *

I have no concerns with my memory

I have a diagnosed memory condition such as dementia

I have new concerns regarding my memory

Do you or your relatives have any concerns about your mood? *

I have no concerns with my mood

I have a diagnosed memory condition such as depression or anxiety

I have new concerns regarding my mood

Do you have any difficulties talking? *

Yes, doctors are aware

Yes, this is a new problem

No difficulties with speech

Do you have any difficulties swallowing? *

Yes, doctors are aware

Yes, this is a new problem

No difficulties with swallowing

Do you have any difficulties with passing urine (going for a wee)? *

Yes, doctors are aware

Yes, this is a new problem

No difficulties

Do you have any difficulties with opening your bowels (going for a poo)? *

Yes, doctors are aware

Yes, this is a new problem

No difficulties

Your Blood Pressure

Please provide at least seven days of blood pressure readings.

If you do not have access to a home blood pressure device, please visit the practice and use the machine in our waiting area and then submit this form.

Day 1

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurement

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Day 2

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 3

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 4

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 5

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 6

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 7

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Height:

Height unit:

Inches

CM

Weight:

Weight unit:

Stone

KG

If we need to contact you to discuss anything related to your form when is the best time to contact you? *

E.g. Monday AM/PM, Tuesday AM/PM

*

I confirm that the information provided is accurate to the best of my knowledge

Tell us whether you accept cookies

Smoking and Vaping

Your Health Information

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure