Chronic disease annual review

Section

*

Confirmation of consent for information about your/the patient’s health to be sent to the email address provided

Height: *

Weight: *

Blood Pressure (if known):

Do you smoke? *

Yes

No

Ex-smoker

How many cigarettes do you smoke in a day? *

1 to 9

10 to 20

20 – 40

More than 40

When did you quit? *

Quitting smoking is one of the most important things you can do for your health.

Further information and advice can be found at www.nhs.uk/smokefree.

What is your diet like? *

Good (5 portions of fruit and veg today, I watch how many carbohydrates and sweet snacks I have)

Average (aim for 5 a day, I am aware of what a healthy balance diet involves but do not always stick to it)

Poor (I struggle to eat a balanced diet and eat mainly processed and junk food)

You might want to have a look at this more detailed questionnaire.

General Practice Physical Activity Questionnaire

Please tell us the type and amount of physical activity involved in your work. *

I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.)

I spend most of my time at work sitting (such as in an office)

I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.)

My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)

My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

During the last week , how many hours did you spend on each of the following activities?
Please answer whether you are in employment or not.

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc. *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Cycling, including cycling to work and during leisure time. *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Walking, including walking to work, shopping, for pleasure etc. *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Housework/Childcare *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Gardening/DIY *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

How would you describe your usual walking pace? *

Slow pace (i.e. less than 3 mph)

Steady average pace

Brisk pace

Fast pace (i.e. over 4 mph)

Carers

Are you a carer? *

Yes

No

You can register as a carer by using our Register as a Carer form.

Who is your next of kin?

Full Name: *

Contact Details: *

Are you happy for us to contact them in an emergency? *

Yes

No

Your Medication

Do you take all your medications as prescribed? *

Yes

No

Can you tell us what you are not taking and why? *

Do you feel you understand what your medications are for? *

Yes

No

Further Information

Have you had any problems with your memory over the past 6 months that has caused you or others concern? *

Yes

No

Have you felt dizzy or unbalanced and/or at risk of falls over the past 6 months? *

Yes

No

Is there anything else you would like to tell us? *

Is there anything you would like advice on in particular? *

We will review your information and get back to you any advice we feel might be helpful to you and let you know when your blood test and pulse check is due.

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Section

General Practice Physical Activity Questionnaire

During the last week , how many hours did you spend on each of the following activities? Please answer whether you are in employment or not.

Carers

Who is your next of kin?

Your Medication

Further Information

During the last week , how many hours did you spend on each of the following activities?
Please answer whether you are in employment or not.