CLINICAL IMAGING & RESEARCH DEPARTMENT   The Wellington Hospital
Wellington Place
London NW8 9LE
Tel No. 020 7483 5062 Fax No. 020 7483 5083 		 
 
       
  Name : (optional)
  Date of Birth :
  Sex : Male Female
  Ethnicity :
  Have you been referred for a cardiac scan and If so, which scan? :
  Name of your cardiologist (if applicable): :
  Please insert your e-mail address: : (required)
    :  
  Heart Disease Risk Profile :  
1. Do you have a history of high cholesterol : Yes No
2. Do you take any tablets for high cholesterol : Yes No
3. What is your total cholesterol level? :
4. What is your HDL level: :
5. What is your LDL level: :
6. What is your Triglyceride level :
7. Do you have a history of high blood pressure? : Yes No
8. Do you take any tablets for high blood pressure? : Yes No
9. Do you smoke? : Yes No
  If yes, how many per day?   Cigarettes/Cigars
  If you have smoked in the past, when did you quit? Years/months : Years/Months
10 Do you have a history of Diabetes? : Yes No
  If yes, how is it controlled?   Diet Tab Insulin
11. Any family history of heart attack?   Yes No
  If yes please indicate: Age    
  Mother/Father  
  Sibling  
  Grand Parent  
12. Any family history of stroke?   Yes No
  If yes please indicate: Age    
  Mother/Father  
  Sibling  
  Grand Parent  
  Do you have any chest pain/chest discomfort?   Yes No
  Jaw pain?   Yes No
  Arm pain?   Yes No
  Breathlessness?   Yes No
  If yes: What is the nature of pain?  
  Where do you feel the pain?  
  How long does the pain last?  
  Is the pain worse on exertion/walking?   Yes No
  Food intake   Yes No
  Does the pain get better after rest?   Yes No
  Glyceryl Trinitrate Sublingual spray   Yes No
  Does the pain/breathlessness affect your day to day activities?
  No Mild restriction Moderate restriction Severe restriction
  Past Medical Problems:    
  Have you ever had a heart attack?   Yes No
  Have you ever had a stroke?   Yes No
  Have you ever had a mini-stroke?   Yes No
  Do you suffer from angina?   Yes No
  Do you suffer from asthma?   Yes No
  Do you have any kidney problems that you know of?   Yes No
  Do you have a history of Rheumatoid Arthritis?   Yes No
  Do you have irregular heart-rate (Atrial fibrillation)?   Yes No
  Did you ever have any of these tests/interventions? (please tick the ones you had)
1. ECG    
2. Exercise stress test (Treadmill test)    
3. Myocardial Perfusion Scan (Thalllium or MIBI scan)
4. Stress Echocardiogram
5. Coronary Angiography    
6. Coronary Angioplasty    
7. Bypass Surgery    
       
  What medications are you currently taking?  
       
       
     
  Enter Code :