Ischaemic heart disease questionnaire

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Ischaemic heart disease questionnaire
For General Practitioners
Ischaemic heart disease questionnaire
Please complete in BLOCK CAPITALS and in ballpoint pen.
To be completed by:
Our reference number
Agent reference
1. Patient’s details
Policy/Reference number
­­­­­Full forename(s)
Title
Surname
Mr / Mrs / Miss / Ms / Other – please specify
Date of birth (dd/mm/yyyy)
2. Medical questions
2.1 Please tell us:
a. the exact diagnosis
2.2 If MI has been diagnosed, please tell us the
number and type of infarctions (for example
anterior, inferior, subendocardial, etc).
b.the date of first symptoms (dd/mm/yyyy)
2. Medical questions – continued
2.3 Has the patient undergone a coronary
angiogram?
2.7 Are there any ongoing symptoms of
ischaemic heart disease?
No
No
Yes – give full details
Y
es – give full details (for example
infrequent minor symptoms, symptoms
with everyday activity, severe functional
limitation). Alternatively, please tell us the
NYHA classification
Vessel affected
% stenosis
2.4 Has PTCA or CABG been carried out?
No
Y
es – give full details, including the
number and location of vessels involved
(for example, Cx, RCA, LAD)
2.5 Is the patient’s LV function normal?
Yes
o – give full details, including the N
degree of impairment, ejection fraction and LVEDP, if available
2.8 Please tell us the dates and results of any
resting or exercise ECGs.
2.9Please tell us the results of any other cardiac
investigations (for example cardiac enzymes,
ECHO, thallium scan, etc).
2.10Please tell us the patient’s most recent BMI
reading.
Date (dd/mm/yyyy)
2.6 Please give details of any current treatment
including drug names and doses
BMI
2.11 What were the last three BP readings?
Date (dd/mm/yyyy)
Reading
Page 2 of 4
2. Medical questions – continued
2.12 What were the last three lipid readings?
Date (dd/mm/yyyy)
Total cholesterol
2.13Does the patient have any of the following
co-existing conditions?
HDL
Trigs
2.16 Does the patient have any history of:
a. excessive alcohol intake?
Peripheral vascular disease
No
Yes
No
Diabetes
No Yes
Arrhythmia
No Yes
Yes – give dates (dd/mm/yyyy) and
details
If Yes, to any of the above – give details,
including their exact diagnosis, treatment and
the frequency of their symptoms.
b.smoking?
2.14Does the patient have any valvular heart
disease?
No
No
Yes – give details, if known, including
how many cigarettes they smoke(d) a
day and the date they stopped, if
applicable
Yes – tell us the exact diagnosis, which
valves are affected and how severe the
disease is
Is there any information in your report that
2.17
we shouldn’t release to the patient because
this would cause serious physical or mental
harm to them or another person?
2.15 Are there any other complicating factors?
No
No
Yes – give details
Yes – give full details
Please send us copies of any related
hospital reports.
Page 3 of 4
3.Signature
Date (dd/mm/yyyy)
Signature
7
7
Aegon is a brand name of Scottish Equitable plc. Scottish Equitable plc, registered office: Edinburgh Park, Edinburgh EH12 9SE.
Registered in Scotland (No. 144517). Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct
Authority and the Prudential Regulation Authority. Financial Services Register number 165548. An Aegon company. www.aegon.co.uk
© 2016 Aegon UK plc
IP 00251751 09/16

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