Heart Health Check risk assessment	
1. Practice details	
Practice name: 	<<Practice/Location:Name>>   	
Practice address: 		Street:	<<Practice/Location:Address>>	
	Phone:	<<Practice/Location:Phone>>	
GP name: 	<<Doctor:Name>>	
GP prescriber No.: 	<<Doctor:Prescriber Number>>	GP provider No.:	<<Doctor:Provider Number>>	
Assessment date:	<<Miscellaneous:Date (long)>>   	
	
2. Patient details	
Name:	<<Patient Demographics:Full Name>>	DOB:	<<Patient Demographics:DOB>>	
Sex:	<<Patient Demographics:Sex at Birth>>	Age:	<PtAge>	
Ethnicity/cultural identity:	<<Patient Demographics:Ethnicity>>         Postcode:  <<Patient Demographics:Address Preferred Postcode>>	
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>>mHg	
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:
<<Clinical Details:Allergies/Adverse 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):>>mol/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 weekly?>>	 	
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 to <10%)
 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?>>	East Asian ethnicity (Chinese, Japanese, Korean, Taiwanese or Mongolian ethnicities)	
Consider reclassifying up a category if:	
<<Coronary artery calcium score 99 units, or =75th pe>>	Coronary artery calcium score > 99 units, or ≥75th percentile for age and sex	
<<First Nations people>>	First Nations people 	
<<Maori, Pacific Islr or South Asian ethnicity (Indi>>	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: <<Final CVD risk category? >>	
     	
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: