CDM Pre-Appointment Form — Kinsealy Medical Centre

Conditions for Today's Appointment *

Tick all that apply. Each condition will show its own questions below.

Hypertension (High Blood Pressure)

Type 2 Diabetes

Cardiovascular Disease / Heart Disease / Angina

Heart Failure

Atrial Fibrillation (AF / Irregular Heartbeat)

COPD (Chronic Obstructive Pulmonary Disease)

Asthma

Stroke / TIA (Mini-Stroke)

Prevention Programme (PP)

Please select at least one condition.

Hypertension — Additional Questions

Do you check your blood pressure at home? *

Yes — I check at home

Average reading over the past week (e.g. 138/82)

Any symptoms since your last visit? *
Tick all that apply

Headaches

Dizziness or lightheadedness

Chest pain or chest tightness

Shortness of breath

Swelling in legs or ankles

None of the above

Approximate alcohol intake (units per week)

Are you taking your blood pressure medication every day? *

Any side effects from your medication you would like to discuss? (optional)

Type 2 Diabetes — Additional Questions

Do you check your blood sugar (glucose) at home? *

Yes — I have a monitor at home

What range have your readings been over the past week or two? (e.g. 5.2–9.4 mmol/L)

Have you had any hypos (low blood sugar) since your last visit? *

A hypo is when blood sugar drops too low — symptoms include shakiness, sweating, confusion, or feeling faint.

Foot health — any sores, cuts, wounds, numbness, or tingling in your feet? *

Any changes in your vision since your last visit? *

When did you last have a Diabetic Eye Screening (DES) check? (optional)

The HSE DES programme sends a letter or text for your eye check — separate from a routine optician visit.

Are you taking your diabetes medication as prescribed? *

Any changes to your diet or exercise since your last visit? (optional)

🧪

Please bring a urine sample to your appointment. A small amount of urine in a clean container is needed to check your kidney health as part of your diabetes review. Collect this first thing on the morning of your appointment.

I confirm I will bring a urine sample to my appointment.

Cardiovascular Disease / Angina — Additional Questions

Have you had any chest pain or chest tightness since your last visit? *

Please briefly describe: when does it happen, how long does it last, what brings it on?

Shortness of breath on exertion (walking, climbing stairs)? *

Any palpitations or awareness of your heartbeat? *

Any swelling in your ankles or legs? *

Smoking status *

Approximately how many per day?

Are you taking all your heart medications as prescribed? *

Heart Failure — Additional Questions

Breathlessness — compared to your last visit? *

Ankle / leg swelling? *

Have you noticed any recent weight gain (possible fluid retention)? *

Approximately how much? (e.g. 2 kg over 2 weeks)

Gaining more than 2 kg in a week can be a sign of fluid build-up — let a member of staff know today if this has happened.

Exercise tolerance — can you climb a flight of stairs? *

Are you taking all your medications as prescribed? *

Atrial Fibrillation (AF) — Additional Questions

Are you currently experiencing palpitations or an irregular heartbeat? *

Any dizziness or lightheadedness? *

Shortness of breath? *

Are you on a blood-thinning medication (e.g. Eliquis / Apixaban, Xarelto, Warfarin)? *

Are you taking it every day without missing doses?

Missing doses of blood-thinning medication significantly increases the risk of stroke.

If on Warfarin — when was your last INR check? (if applicable)

COPD — Additional Questions

How breathless are you generally day-to-day? *

How would you describe your cough? *

How many chest infections or COPD flare-ups since your last visit? *

How often are you using your blue rescue inhaler (e.g. Ventolin / Salbutamol)? *

Smoking status *

Asthma — Additional Questions

The following questions are based on the standard Asthma Control Test (ACT).

Over the past month, how often did you have asthma symptoms (wheeze, cough, shortness of breath, chest tightness)? *

Over the past month, how often were you woken at night by asthma symptoms? *

How many times per week did you use your blue rescue inhaler (e.g. Ventolin)? *

Did asthma limit your daily activities (work, exercise, housework)? *

Are you using your preventer inhaler (brown / purple / red / orange) as prescribed? *

Stroke / TIA — Additional Questions

Have you noticed any new or worsening neurological symptoms since your last visit? *

Please briefly describe what you have noticed

Neurological symptoms include: weakness, numbness or tingling on one side, slurred speech, vision changes, sudden confusion, or difficulty finding words.

Any falls or balance problems since your last visit? *

Any concerns about your memory or concentration? *

Are you taking all your medications as prescribed (especially aspirin or blood thinners)? *

Do you check your blood pressure at home?

Yes

Average reading over the past week (e.g. 128/76)

Prevention Programme (PP) — Additional Questions

Smoking status *

Approximately how many per day?

Approximate alcohol intake (units per week)

How many days per week do you do physical activity or exercise (at least 30 minutes)? *

Any concerns about your diet you would like to discuss? (optional)

Do you check your blood pressure at home?

Yes

Average reading over the past week (e.g. 128/76)

Any new family history of heart disease, stroke, or diabetes since your last visit? *

Any other concerns you would like to discuss at your appointment? (optional)

🧪

Good news — your CDM bloods are free of charge. Depending on your condition and your review type, you may not be due bloods at all. On the day, we carry out the exact blood tests recommended by the HSE for your condition(s) and appointment type, shown in the reference chart below. These are fully covered under the Chronic Disease Management / Prevention Programme — there's nothing for you to pay.

If your doctor or nurse have recommended you need additional tests outside this scheme (or you believe you are due extra blood tests) — you can either have them done privately with us at our standard charge, or we can refer you to the hospital to have the full panel done there instead for free.

How would you like to proceed with your bloods? *

I'm happy to just have the bloods covered under my CDM / Prevention Programme

I think I need additional blood tests — I'd like to give details

What additional tests would you like, or why do you think you need them?

Your doctor or nurse will confirm whether these are needed and let you know about the charge, or arrange a hospital referral if you'd prefer that instead.

Please make a selection.

💪

What is an ABPM? The ABPM is a small device worn on your upper arm for 24 hours. It automatically checks your blood pressure every 30 minutes during the day and every hour at night, giving a much more accurate picture than a single surgery reading.

We recommend an ABPM for patients aged 50 or over with hypertension, cardiovascular disease, type 2 diabetes, heart failure, atrial fibrillation, or a history of stroke or TIA. If unsure, your nurse will advise you at your appointment.

Device Responsibility Agreement

By entering your full name below and ticking the box, you confirm you have read and understood the care instructions above and that you accept responsibility for the ABPM device. Any damage, loss, or failure to return the device may result in a replacement charge.

Full Name — Electronic Signature *

Entering your full name serves as your electronic signature for this responsibility agreement.

Please enter your full name to complete the responsibility agreement.

I confirm I have read the ABPM care instructions above and accept full responsibility for the device while it is in my care.

ℹ️

That is absolutely fine. You can discuss the ABPM with your nurse at your appointment — they will be happy to answer any questions before you decide.

Home Blood Pressure Reading *

As you are not having a 24-hour monitor, please provide a home BP reading. Home readings give a more accurate picture than a single surgery reading — white coat hypertension can cause blood pressure to appear higher in a clinical setting. Take a few readings over several mornings and enter your average.

Please enter a home blood pressure reading (e.g. 128/76 mmHg).

Your CDM / PP Appointment

Arrive fasting — no food or drink (except water) from midnight the night before. Continue all regular medications as normal.

Check in at reception — let staff know you are here for your CDM or Prevention Programme review.

Nurse / Phlebotomist — will take blood samples, check your blood pressure, weight, and height, and fit a 24-hour blood pressure monitor (ABPM) if required. This may take 20–30 minutes.

Doctor review — your GP will review your results and renew your chronic disease prescription. If follow-up is needed, they will contact you.

Your script — a 6-month prescription (CDM) or 12-month prescription (PP) will be issued. A note is sent to your pharmacy to remind you to book your next review when the script is running out.

Bring with you — medication list or tablets, and your ABPM monitor if you already have one fitted from a previous visit.

Reminder — Please Bring a Urine Sample

As you have diabetes, please bring a small urine sample in a clean container to your appointment. This is used to check your kidney health (ACR). The best time to collect it is first thing on the morning of your appointment.

CDM Pre-Appointment Health Update

Form Received

Fasting Required — Please Read Before Your Appointment