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Long-term conditions review

If you prefer, you can print out and complete this hard copy form – please hand it in at Reception the week before your blood test >>

Long term conditions review
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?
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 (or already had) the blood test needed as part of your long-term conditions review?
Please don’t filling out your form at this point.

Please 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 in the week before your blood test, once you’ve taken at least 5 days of blood pressure readings.

Do you have a further follow-up appointment booked, after the blood test?
Please use format day/month/year e.g. 06/09/1978

Your height and weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

If you’d like help with managing your weight, you can self-refer to NHS Lothian’s specialist programme.

For more details please visit their website >>

Smoking status

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.

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’ – the first number is the systolic reading and the last number is the diastolic reading

Day 1

Morning

Evening

Day 2

Morning

Evening

Day 3

Morning

Evening

Day 4

Morning

Evening

Day 5

Morning

Evening

Day 6

Morning

Evening

Day 7

Morning

Evening

Average Readings

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.