Long-term conditions review 2

Hard copy forms are available from Reception if you prefer.

Have you received a letter or text message asking you to complete this form, or been asked to complete it by a doctor or nurse at the Practice?

Yes

Please don’t carry on filling out this form.

This form should only be completed by patients who:

have been asked to do so by a doctor or nurse at the Practice
have been asked to do so via a letter or text message from the Practice

Have you booked a blood test?

Yes

Please don’t complete this form until you’ve booked your blood test.

Contact the Practice after 11am Monday-Friday on 0300 790 6266 or come to the front desk to book the blood test and other follow-up appointments needed first.

Once you’ve done that please submit this form before (or by the day of) your blood test, with at least 5 days of blood pressure readings.

Date of blood test

First name *

Last name *

Email *

Date of birth *

Please use format day/month/year e.g. 06/09/1978

Phone number *

Your height and weight

Weight

Unit of measurement *

Height

Weight

Height

Inches

Weight

lbs

BMI

NHS Lothian Weight Management Programme

If you’d like help with managing your weight, you can self-refer to NHS Lothian’s specialist programme if you meet certain criteria. For more details please visit their website >>

Smoking status

What is your smoking status? *

Smoker

Never smoked

Ex-smoker

I use electronic cigarettes (vapes)

How many cigarettes do you smoke each day? *

Support to stop smoking

Stopping smoking is one of the best things you can do for your physical and mental health. It’s never too late to stop smoking and your health will improve soon after you quit.

NHS Inform has advice to support you every step of the way – from getting ready to stop, making a quit plan, and dealing with cravings. It also has information on how to stop smoking if you are pregnant.

If you’d like additional personalised, free support face-to-face or over the phone then NHS Lothian’s trained practitioners can help – for more details visit the Quit Your Way East Lothian website.

When did you give up smoking? *

Alcohol

How much alcohol do you typically drink each day?

Your blood pressure

Blood pressure monitors can be bought from pharmacies and online. There’s also a blood pressure monitor and scales in our waiting room if needed.
Take readings for at least five days
Take your blood pressure while sitting down
For each blood pressure reading, take two measurements at least 1 minute apart – enter the lowest
Record your blood pressure twice a day: once in the morning, once in the evening
Some blood pressure monitors may display in the format ‘140/80’ and some show the numbers one above the other – the first or top number is the systolic (sys) reading and the last or bottom number is the diastolic (dia) reading

How many days readings do you have to report?

Day 1

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Day 2

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Day 3

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Day 4

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Day 5

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Day 6

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Day 7

Date *

Morning

Systolic morning *

Diastolic morning *

Evening

Systolic evening *

Diastolic evening *

Average Readings

SYSTOLIC AVERAGE

DIASTOLIC AVERAGE

Systolic total

Diastolic total

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

Long-term conditions review 2

Your height and weight

Weight

BMI

NHS Lothian Weight Management Programme

Smoking status

Support to stop smoking

Alcohol

Your blood pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Readings

Privacy Policy

Local Support with aliss

Self-help

Services directory