Stroke or TIA review – Demo clinic

About you

Height (in Meters): *

eg. 1.75

Weight (in Kilograms): *

eg. 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over.

Blood pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Smoking

Smoking status: *

Smoker

Never smoked

Ex smoker

Smoker

What do you mainly smoke?

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week? *

Pipe – How many grams of tobacco do you smoke per week? *

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex smoker

What did you mainly smoke?

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

When did you give up smoking? *

Further questions

Have you had a flu vaccination in the last year? *

Yes

No, but I would like one

No, and I do not want one

Are you taking any anti-coagulant (e.g. Warfarin) or anti-platelet (e.g. Aspirin) medications? *

Yes

No

Please tell us what medication you are taking: *

Terms and conditions *

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.