Anti-hypertensive Questionaire

Patient Medical Record Number

Age:

Patient Gender:

Male

Female

Indigenous Status:

Aboriginal

Torres Strait Islander

Non-indigenous

Allergies:

Smoking Status:

Smoker

Ex-smoker

Non-smoker

Any recreational drug use?

Any co-morbidities? (asthma, COPD, viral respiratory Infection, heart failure, GORD)

Other Medications

Which anti-hypertensive medication (Perindopril or Irbesartan) was initiated and at what daily dose?