GENERAL

• Do you still smoke?
• Would you like help to quit?
• How much alcohol do you drink each week?
• Would you like help to quit?
• Do you use recreational drugs?
• Would you like help to quit?
• How much exercise do you do?
• Would you like help to get started?
• Do you have a balanced healthy diet?
• Would you like with managing your diet?
• Do you need carers?
• Is there anything you would like to ask us about your conditions?

ATRIAL FIBRILLATION

• Are you having any dizziness symptoms or chest pain?
• Managing your blood thinning medication
• Are you having any side effects?
• Are you able to take your medication every day as prescribed?
• Have you had any bleeding or increase in bruising?

HEART DISEASE

• Do you get any chest pain?
• Is this at rest?
• Is this with just light activity – walking?
• Is this with strenuous activity?
• Do your legs swell?
• How many flights of stairs can you walk up before having to stop to catch your breath?
• Do you have to stop due to your breathing?
• Do you have to stop due to your legs?
• Do you have to stop due to chest pain?
• Do you get palpitations?

HEART FAILURE

• Do your legs swell?
• Do you get palpitations? (heart racing)
• Can you wash and dress yourself or do you need help?
• Have you been asked to watch your weight?
• Has your weight gone up or down by more than 10% over the past 3 months?
• How many flights of stairs can you walk up before having to stop to catch your breath?
• Do you have to stop due to your breathing?
• Do you have to stop due to your legs?
• Do you have to stop due to chest pain?
• Do you get palpitations?
• Are you under a hospital Heart Failure Team?
• Have you had a blood test in the last year?
• Have you had an appointment with the hospital in the last year?
• Have you had a heart scan (Echo) in the last year? (you won’t need one every year)
• Do you have a carer to help look after you?

DIABETES

• Do you feel well?
• How careful is your diet?
• Are you struggling to keep your weight down?
• Would you like some help and advice about your diet?
• Do you regularly check your weight?
• Is it stable or has it changed by more than 10% in the last 6 months?
• Have you had any numbness in your hands or feet?
• If you have exactly where and for how long?
• Are you having hypoglycaemic turns? (Hypos)?
• If so, how often and how severe?
• Do you need to check your sugar levels regularly?
• Are your blood sugar levels stable or do they swing up and down?
• Are your blood sugar levels running high?
• Are you worried about your sugar levels?
• Are you under the care of the hospital for your diabetes?
• When did you last have a blood test for your diabetes?
• When were you last seen for your diabetes review?

KIDNEY DISEASE

• Are you feeling more tired than usual?
• Have you had any new medication started in the last 6 months?
• When was your last kidney blood test?

MENTAL HEALTH

• Are you managing at the moment?
• Do you have someone at home to support you?
• Are you sleeping ok?
• Do you feel so bad that you might need to hurt yourself?
• Are you eating well?
• Are you still able to manage your job?
• Do you manage to get out of the house and see people?
• Do you drink alcohol or take recreational drugs to help you manage your mental health?

DEMENTIA

Mental health screen:

• Sleep
• Appetite
• Memory
• Depression
• Behaviour: challenging/ self harm/ overactivity

HYPERTENSION

• Do you check your own Blood Pressure at home?
• Could you give us a record of your average Blood Pressure over the last 7 days please?
• How often do you check your Blood Pressure?
• What do you do if the Blood pressure is high?
• Do you get regular headaches?
• When did you last have a blood test for you Blood Pressure?
Are you on medication for blood pressure and do you have any side effects?

ASTHMA

• How often do you use your blue inhaler?
• If you need to use it more than once a day we should look to adjust your other inhalers to make you safer.
• How long ago did you have an asthma attack?

In the last month:

• have you had difficulty sleeping because of your asthma symptoms (including cough)?
• have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
• has your asthma interfered with your usual activities (for example, housework, work/school, etc.)?

CHRONIC LUNG DISEASE & EMPHYSEMA

MRC Breathlessness Scale

• Not troubled by breathless except on strenuous exercise
• Short of breath when hurrying on a level or when walking up a slight hill
• Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
• Stops for breath after walking 100 yards, or after a few minutes on level ground
• Too breathless to leave the house, or breathless when dressing/undressing

Assess Baseline symptoms

• How far can you walk without stopping?
• Can you wash and dress yourself without stopping?
• Do you have a cough?
• How tired do you get?
• How many exacerbations have you had over the last year?
• How long is it since you had a session of Pulmonary Rehabilitation?
• Are you having any problems with your inhalers?

RHEUMATOID ARTHRITIS Assessment of disease activity, pain and functional ability

• What activities do you find difficult?
• Is it pain or loss of function that stops you?
• What can we do to help?
• Physiotherapy
• Help managing your pain relief
• Help accessing support – carers, DLA
• Depression screening
• Over the last 2 weeks, how often (not at all, some days, most days or every day) have you been bothered by any of the following problems?
• Little interest or pleasure in doing things
• Feeling down, depressed, or hopeless
• Trouble falling/staying asleep, sleeping too much
• Feeling tired or having little energy
• Poor appetite or overeating
• Feeling bad about yourself or that you are a failure or have let yourself or your family down
• Trouble concentrating on things, such as reading the newspaper or watching television.
• Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual.
• Thoughts that you would be better off dead or of hurting yourself in some way.
• If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
• Are you under a Hospital Team for your Arthritis?
• When did they last see you?
• When did you last have any blood tests?
• Do you have a family history of heart disease?
• How old was your family member when they started having heart problems?