• Home Vitals & Heart Health Check

    Patients fill this in at home. Match the PDF exactly in wording, section order, and clinical content.

  • Your details

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Why are you sending these readings?*
  • Date of last dose change
     - -
    2 digit month, 2 digit day, 4 digit year

  • Your readings

  • Date taken*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time taken*
  • Time you took today’s dose
  • Reading 1
  • Reading 2
  • Which arm did you use?
  • Is your pulse regular?

  • Heart health questions

  • Do you experience chest pain or discomfort?*
  • Do you get shortness of breath?*
  • Do you have palpitations or an irregular heartbeat?*
  • Do you feel dizzy or light-headed?*
  • Do you have swelling in your ankles or feet?*
  • Have you ever been diagnosed with a heart condition?*
  • Are you currently taking medication for your heart?*

  • How are you getting on?

  • Side effects*

  • Declaration

  • Declaration*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • SAFETY NET

    This form is not checked in real time. Chest pain, fainting or severe breathlessness: call 999. Feeling unwell or unsure what to do: call NHS 111. Low mood or thoughts of harming yourself: call NHS 111 and choose the mental health option, or Samaritans on 116 123 (free, 24 hours). Questions about your medication: contact Focus Gently via focusgently.com.

     

    Call 999 now if you have:

    chest pain or tightness  ·  fainting or collapse  ·  severe breathlessness  ·  blood pressure of 180/120 or higher with a severe headache, blurred vision or confusion.

    If it is 180/120 or higher with no symptoms, rest for 5 minutes and measure again. If it is still that high, call NHS 111 the same day and do not take your next dose.

  • Should be Empty: