Exercise: Do you do any form of exercise/activity? Smoking Status: Do you have a sedentary job/lifestyle? If you do not smoke, have you ever smoked? When did you stop? How many a day? If Do How Alcohol yes, you often what Status: do do you you If do yes, do? this? put X in box of what you smoke Cigarettes Cigars Pipe Other (one unit = ½ pt beer, small glass of wine, pub measure of spirits) What is your average weekly consumption of alcohol in units? If less than 1 unit, how many in a month? Did you regularly drink more in the past? If so, how many units a week? Family History: Have close family members suffered from any of the following? Please put M for Mother, F for Father, S for Sister or B for Brother High Diabetes Type 1 Diabetes Type 2 Office Use only Blood Stroke Heart Attack Pressure High Cholesterol 2nd Pulse B/P: : reading: Pressure: Hips: Waist:Hip: Heart Vascular PPT: SI Range SI: Rate: Age: Recommendations:
Exercise: Do you do any form of exercise/activity? If yes, what do you do? How often do you do this? Do you have a sedentary job/lifestyle? Smoking Status: Do you If yes, put X in box of what you smoke Cigarettes Cigars Pipe Other How many a day? If you do not smoke, have you ever smoked? When did you stop? Alcohol Status: (one unit = ½ pt beer, small glass of wine, pub measure of spirits) What is your average weekly consumption of alcohol in units? If less than 1 unit, how many in a month? Did you regularly drink more in the past? If so, how many units a week? Family History: Have close family members suffered from any of the following? Please put M for Mother, F for Father, S for Sister or B for Brother Stroke Heart Attack High Blood Pressure High Cholesterol Diabetes Type 1 Diabetes Type 2 Office Use only B/P: 2nd reading: Pulse Pressure: Hips: Waist:Hip: Heart Rate: PPT: SI Range : SI: Vascular Age: Recommendations:
Cardiovascular_Assessment-web.docx