Long Term Condition Review

If you have been advised by the surgery to submit a Long Term Condition Review, please use this form.

Long Term Condition Review

Long Term Condition Review

Section

Have you had a stroke/TIA? *

Stroke/TIA

Are you experiencing any further difficulties since your stroke/TIA?

Do you have hypertension (high blood pressure)? *

Hypertension

Do you ever suffer from headaches and/or dizziness?

Do you have coronary heart disease (previous heart attack/angina)? *

Coronary Heart Disease

Do you experience any chest pain?
Do you regularly use a GTN spray?

General

Please specify in metres or feet
Please specify in kilograms or stone

To correctly measure waist circumference:

  • Find the bottom of your ribs and the top of your hips
  • Wrap a tape measure around your waist, midway between these points
  • Breathe out naturally before taking the measurement
Would you like to receive an influenza immunisation (these are generally offered between September and the end of November)?
Do you have any concerns with your medication?
Do you have any concerns about management of your long term condition?
Are you currently doing any regular exercise?

Smoking

Smoking status:
How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Please ask at reception for more information about giving up smoking.

How many cigarettes did you smoke in a day?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Blood Pressure

Please use this date format: DD/MM/YYYY.
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Before submitting your Long Term Condition Review

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