Pre-consultation: Cardiovascular Risk Assessment

First name *

Last name *

Email *

Phone *

Date of birth *

What is your sex? *

Male

Female

What is your ethnicity? *

Postcode (for deprivation score)

Used for QRISK3 calculation - socioeconomic deprivation affects cardiovascular risk

Have you been diagnosed with any of the following?

Angina or heart attack

Stroke or TIA

Atrial fibrillation

Type 1 diabetes

Type 2 diabetes

Chronic kidney disease

Rheumatoid arthritis

Systemic lupus erythematosus (SLE)

Severe mental illness

Erectile dysfunction

Migraine

What is your HbA1c (if known)?

Blood sugar control - QRISK3 risk factor

How long have you had diabetes?

Do you have diabetes complications?

Eye damage (retinopathy)

Kidney damage (nephropathy)

Nerve damage (neuropathy)

Foot problems

If you have chronic kidney disease, what is your stage?

What is your eGFR (if known)?

If you have had a heart attack or stroke, when was this?

What treatment did you receive for your heart attack/stroke?

Angioplasty and stent

Bypass surgery

Thrombolysis

Medical management only

Other

Blood pressure (if you know it)

If not known, we'll measure it at your consultation

Are you taking blood pressure medication?

Yes

No

Are you taking statins or cholesterol medication?

Yes

No

Are you taking corticosteroids (e.g. prednisolone, dexamethasone)?

QRISK3 flag - corticosteroids increase cardiovascular risk

Yes

No

Are you taking atypical antipsychotics (e.g. quetiapine, olanzapine, risperidone)?

QRISK3 flag - atypical antipsychotics increase cardiovascular risk

Yes

No

Does anyone in your family have a history of early heart attack or stroke (before age 60)?

Yes

No

Does anyone in your family have familial hypercholesterolaemia (very high cholesterol)?

Yes

No

Does anyone in your family have a history of sudden cardiac death?

Yes

No

What is your smoking status? *

Never smoked

Former smoker

Current smoker - light (1-9 per day)

Current smoker - moderate (10-19 per day)

Current smoker - heavy (20+ per day)

Do you use e-cigarettes/vaping?

Yes

No

How many units of alcohol do you drink per week?

1 unit = half pint of beer, small glass of wine, or single measure of spirits

Do you ever binge drink (6+ units in one occasion)?

Yes

No

Do you use recreational drugs (particularly cocaine)?

Yes

No

How would you describe your activity level? *

Sedentary - little or no exercise

Light activity - 1-2 times per week

Moderate activity - 3-4 times per week

Active - daily exercise

Athletic training - training multiple times per week

What types of exercise do you do?

Walking

Running

Cycling

Swimming

Strength training

Yoga

Team sports

Other

How many hours of sleep do you get per night on average?

Less than 6 or more than 9 hours is associated with increased cardiovascular risk

Waist circumference (if known)

Measure at your navel - central obesity is a key risk factor

Weight

Height

VO2 max (if you know this from your fitness app)

Check Apple Health, Garmin Connect, Strava, or your fitness tracker app

Resting heart rate

Check your wearable or count your pulse for 60 seconds

Heart rate variability (if known from your wearable)

Usually shown in Apple Health, Garmin, or Oura Ring

Average daily steps

Do you experience chest pain or discomfort on exertion? *

CRITICAL - please answer this carefully

Yes

No

Do you experience shortness of breath on exertion?

No shortness of breath

Mild (can still talk)

Moderate (have to stop and catch breath)

Severe (have to sit down)

Do you experience palpitations (feeling your heartbeat)?

Yes

No

Do you have swollen ankles?

Yes

No

Do you experience dizziness or fainting?

Yes

No

Do you experience unexplained fatigue or tiredness?

Yes

No

Total cholesterol (if known)

LDL cholesterol (if known)

HDL cholesterol (if known)

Triglycerides (if known)

HbA1c (if known)

ApoB (if known)

Lipoprotein(a) / Lp(a) (if known)

Genetic risk marker - only needs testing once in a lifetime

High-sensitivity CRP (if known)

eGFR or creatinine (if known)

When were these blood tests done?

Which assessment package interests you?

Heart Check - £150 (QRISK3 + core bloods + consultation)

Advanced Heart Assessment - £400 (above + advanced panel + consultation)

Complete Cardiovascular Assessment - £1,000 (above + cardiac imaging + consultation)

Not sure - want advice

What prompted this assessment?

Family history concerns

Abnormal previous test results

GP recommendation

Wearable data concerns

General prevention

Insurance or employment medical

Symptoms

Other

Anything else you'd like us to know?

Please list all your current medications

Include doses and frequency - helps us identify potential drug interactions

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

QRISK3 Cardiovascular Risk Assessment

What is your sex? -

What is your ethnicity? -

Postcode (for deprivation score) -

Medical History

Have you been diagnosed with any of the following? -

What is your HbA1c (if known)? -

How long have you had diabetes? -

Do you have diabetes complications? -

If you have chronic kidney disease, what is your stage? -

What is your eGFR (if known)? -

If you have had a heart attack or stroke, when was this? -

What treatment did you receive for your heart attack/stroke? -

Blood pressure (if you know it) -

Are you taking blood pressure medication? -

Are you taking statins or cholesterol medication? -

Are you taking corticosteroids (e.g. prednisolone, dexamethasone)? -

Are you taking atypical antipsychotics (e.g. quetiapine, olanzapine, risperidone)? -

Family History

Does anyone in your family have a history of early heart attack or stroke (before age 60)? -

Does anyone in your family have familial hypercholesterolaemia (very high cholesterol)? -

Does anyone in your family have a history of sudden cardiac death? -

Smoking & Substance Use

What is your smoking status? -

Do you use e-cigarettes/vaping? -

How many units of alcohol do you drink per week? -

Do you ever binge drink (6+ units in one occasion)? -

Do you use recreational drugs (particularly cocaine)? -

Lifestyle & Fitness

How would you describe your activity level? -

What types of exercise do you do? -

How many hours of sleep do you get per night on average? -

Waist circumference (if known) -

Weight -

Height -

VO2 max (if you know this from your fitness app) -

Resting heart rate -

Heart rate variability (if known from your wearable) -

Average daily steps -

Current Symptoms

Do you experience chest pain or discomfort on exertion? -

Do you experience shortness of breath on exertion? -

Do you experience palpitations (feeling your heartbeat)? -

Do you have swollen ankles? -

Do you experience dizziness or fainting? -

Do you experience unexplained fatigue or tiredness? -

Recent Blood Results (if available)

Total cholesterol (if known) -

LDL cholesterol (if known) -

HDL cholesterol (if known) -

Triglycerides (if known) -

HbA1c (if known) -

ApoB (if known) -

Lipoprotein(a) / Lp(a) (if known) -

High-sensitivity CRP (if known) -

eGFR or creatinine (if known) -

When were these blood tests done? -

Assessment Package

Which assessment package interests you? -

Motivation & Goals

What prompted this assessment? -

Anything else you'd like us to know? -

Current Medications

Please list all your current medications -

Anything else for your doctor?