Cardiovascular Questionnaire Name First Last Date of Birth PhoneCardiovascular ReviewPlease complete the following questions to allow your health care professional to assess your cardiovascular health. This questionnaire is for a routine review of your symptoms. If you are experiencing chest pain, severe shortness of breath or other concerning symptoms, please follow your care plan (if you have one) or ring your GP or 999 immediately Your Cardiovascular HealthIf you have angina do you fell this is well controlled? Yes No Not Applicable How would you rate your breathing? Asymptomatic with no limitations of physical activity. Mild symptoms with slight limitation of physical activity, but still comfortable at rest. Moderate symptoms with marked limitation of physical activity, but still comfortable at rest. Server symptoms causing inability to perform physical activity without discomfort, symptoms at rest. Is this new and/ or getting worse? Yes. No. Do you have any leg swelling? If yes, please telephone the surgery for further assessment if this swelling is new or getting considerably worse No – No foot, ankle or leg swelling Yes – Swelling of feet only Yes – Swelling of ankles Yes – Swelling of legs Is this new and/ or getting worse? Yes No Post Custom Field Optional Comments OptionalThis field is for validation purposes and should be left unchanged.