Name | Telephone number | ||
---|---|---|---|
Gender | Age | ||
Personal history | Previous myocardial infarction/angina of effort/peripheral arterial disease/cerebral infarction | ||
Family history | Angina or heart attack in: | ||
mother/sister aged < 65 years | |||
father/brother aged < 55 years | |||
Smoking habit | |||
Current | Cigarettes | /day | |
Past | Cigarettes | /day | |
Length of exposure | Years | ||
Other tobacco | |||
Diabetes mellitus | Yes/no | ||
Age at menopause | Years | ||
Body weight | kg | Height | cm |
Blood pressure | Systolic | mm Hg | |
(treated hypertension yes/no) | Diastolic | mm Hg | |
Xanthelasmata | Yes/no | ||
Other xanthomata (eg, tendon) | Yes/no | ||
Corneal arcus in patient aged < 50 years | Yes/no | ||
Cholesterol | mmol/l | ||
HDL cholesterol | mmol/l | ||
Date of last tetanus booster | |||
Date of last cervical smear |
NB If angina is diagnosed for the first time the screening nurse should refer the patient to the doctor. Referral to a cardiologist for full evaluation may be important because further investigation may be indicated on prognostic grounds even if symptoms are not severe. Of more immediate concern is lifestyle advice, control of blood pressure, blood cholesterol, and diabetes mellitus, and therapy with low dose aspirin.