Heart Health Check risk assessment	
1. Practice details	
Practice name: 	<Practice>    	
Practice address: 		Street:	<DrStreet>	
	City:	<DrCity>	State:	<DrState>	Postcode:	<DrPostcode>   	
	Phone:	<UsrPhone>	
GP name: 	<UsrName>	
GP prescriber No.: 	<DrPrescriberNo>	GP provider No.:	<DrProviderNo> 	
Assessment date:	<FormattedDate>    	
	
2. Patient details	
Name:	<PtFullName>	DOB:	<PtDoB>	
Sex:	<PtSex>	Age:	<PtAge>	
Ethnicity/cultural identity:	<PtEthnicity>	
Verbal consent?	<Verbal consent given?>	
	
3. Patient medical history	
<Moderate-severe chronic kidney disease?> Moderate-severe chronic kidney disease (People with moderate-to-severe chronic kidney disease are automatically considered to be at high risk of CVD. This includes people with sustained eGFR <45mL/min/1.73m2 or persistent uACR>25mg/mmol (men) or persistent uACR>35mg/mmol(women) 	
<Familial hypercholesterolaemia?> Familial hypercholesterolaemia (People with diagnosed familial hypercholesterolaemia (FH) are automatically considered to be at high risk of CVD. Treat according to Australian guidelines for managing FH. FH-specific calculators may be useful)	
Family history of	
CVD:	<Family History - CVD>	
Details:	<Family history - CVD details>	
Diabetes:	<Family History - Diabetes>	
Details:	<Family history - Diabetes details>	
History of Atrial Fibrilllation? 	<History of Atrial Fibrilllation?>	
Hypertension:	<Present>	 During pregnancy <Hypertension during pregnancy>	
Other relevant history:	<Other relevant family history>	
	
4. Physical examination & investigations	
Blood Pressure	
Systolic blood pressure 
<Systolic blood pressure>mmHg	Diastolic blood pressure 
<Diastolic blood pressure>mmHg	
Lipids	
Date of investigation:	 <Date of most recent lipid results>  	
Total cholesterol:	 <Total cholesterol (mmol/L)> mmol/L	
LDL cholesterol:	 <LDL cholesterol (mmol/L)> mmol/L	
HDL cholesterol:	 <HDL cholesterol (mmol/L)> mmol/L	
Non-HDL cholesterol:	 <Non-HDL cholesterol (mmol/L)> mmol/L	
Triglycerides:	 <Triglycerides (mmol/L)> mmol/L	
Ratio of total cholesterol to HLD cholesterol	<Ratio of total cholesterol to HLD cholesterol>	
Allergies:
<Reactions>	
Body mass index (BMI): <BMI>  Weight: <Weight>   Height: <Height>  Waist Circumference: <Waist Circumference>	
Diabetes
<No diabetes> No       	
<No diabetes> No diabetes 	<Type 1> Type 1	
<Type 2*>  Type 2*	<Gestational> Gestational	
* If Type 2 diabetes is present, please complete the below section:	
Years since diabetes diagnosis: <Years since diabetes diagnosis?> Glycated haemoglobin (HBA1C): <Glycated haemoglobin (HBA1C):>mmol/mol OR <OR %>% mg/mmol   	
uACR: <uACR>              mg/mmol	<eGFR> mL/min/1.73m2	OR    <eGFR >=  90>	
Use of insulin within the last 6 months? <Use of insulin within the last 6 months?>	
5. ECG (if applicable)	
Most recent ECG date:	<Most recent ECG date (if applicable)>	
Details:	<Details>	
6. Medications 	
Use of CVD medicines within last 6 months:	
<Blood pressure-lowering medicines>	Blood pressure-lowering medicines 	
<Lipid-modifying medicines>	Lipid-modifying medicines	
<Antithrombotic medicines>	Antithrombotic medicines	
<None>	None	
7. Other Lifestyle Factors	
Smoking status             	
Smoking status? 	<Smoking Status?>	
Diet	     	
Describe your diet:	<Describe your diet>	
No. portions of fruit and vegetables per day?	<No. portions of fruit and vegetables per day?>	
Alcohol intake	
Describe your alcohol intake:	<Describe your alcohol intake>	
How many standard alcoholic drinks do you have per week?	<How many standard alcoholic drinks do you have per week?> 	 	
Physical activity	
How often do you exercise?	<How often do you exercise> 	 	
What kind of exercise?	<What kind of exercise do you do?>	
	
8. CVD risk score (according to Aus CVD Risk calculator at cvdcheck.org.au	
Risk score:	<Risk Score %>%	
Risk of a stroke or heart attack in the next 5 years:	 Low (<5%)
 Intermediate  (5 to10%)
 High (≥10%) 	
9. Risk reclassification factors	
Reclassification factors are of the most value when the person's risk lies close to a risk threshold, as a small shift in risk estimate may result in their risk being categorised in a different risk category. 	
Consider reclassifying down a category if:	
<Coronary artery calcium score of 0>	Coronary artery calcium score of 0	
<East Asian ethnicity (Chinese, Japanese, Korean, Taiwanese or Mongolian ethnicities)>	East Asian ethnicity (Chinese, Japanese, Korean, Taiwanese or Mongolian ethnicities)	
Consider reclassifying up a category if:	
<Coronary artery calcium score  99 units, or >=75th percentile for age and sex>	Coronary artery calcium score > 99 units, or ≥75th percentile for age and sex	
<First Nations people>	First Nations people 	
<Maori, Pacific Islander or South Asian ethnicity (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian ethnicities)>	Maori, Pacific Islander or South Asian ethnicity (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian ethnicities)	
<Family history of premature CVD>	Family history of premature CVD	
<Chronic kidney disease>	Chronic kidney disease	
<People living with severe mental illness>	People living with severe mental illness	
Final CVD risk category: <Low (<5%)> Low (<5%)   <Intermediate  (5-10%)> Intermediate  (5 to 10%)  <High (=10%)>High (≥10%) 	
     	
10. Management and follow-up	
Does the patient require a Healthy Heart Plan?	<Does the patient require a Healthy Heart Plan?>	
Date of next consultation:	<Date of next consultation>	
Recall added into clinic software:	<Recall added into clinic software>	
Additional Notes: