Heart Failure Review Form

As part of our commitment to the care of your heart failure we would ask you to complete this questionnaire along with the annual medication review form.

Last Updated: 12/05/2020

Your Details

Name *

Date of Birth *

Contact Number *

Email Address *

Breathlessness Review

Smoking

Do you smoke? *

Never

Stopped within the last year

Stopped >1yr ago

1-10 per day

11-20 per day

21-30 per day

+30 per day

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form

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Heart Failure Review Form

Further Information