Long Term Conditions

Please complete the following form and submit to the practice prior to your long term conditions review.

Long Term Conditions

Which conditions have you been diagnosed with?

Height and Weight

If you are overweight would you be interested in a referral to:
It is important to maintain a healthy weight, exercise regularly where possible, maintain alcohol consumption within the national guidance of 14 units a week and eat a balanced diet with fruit and vegetables. *
Dietary advice: Eat at least 5 portions of a variety of fruit and vegetables every day (see 5 A Day). Base meals on higher fibre starchy foods like potatoes, bread, rice or pasta. Have some dairy or dairy alternatives if you are intolerant (such as soya drinks). Eat some beans, pulses, fish, eggs, meat and other protein • choose unsaturated oils and spreads, and eat them in small amounts. Drink plenty of fluids (at least 6 to 8 glasses a day). If you're having foods and drinks that are high in fat, salt and sugar, have these less often and in small amounts. *

BP: Please complete this if you have a home blood pressure machine

If you do not have a home blood pressure machine, please come into the surgery and use the machine in reception. Please make a note of this reading and complete this form.

Smoking

What is your current Smoking Status?
Would you like help to give up smoking?

Physical Activity

What type of exercise do you do?
Would you like a referral to a physical activity programme?
Do you experience any left sided chest pain?

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? *
Alcohol: Suggested maximum 14 units a week. If you regularly drink as much as 14 units per week, it's best to spread your drinking evenly over three or more days. *

Family History

Please select:

Carers Assessment

Are you currently a carer?
Would you like some assistance as your role as a carer?
Please select:

Memory Assessment

Do you or others have any concerns about your memory?

Self Management

Would you like a referral to a programme which aims to help you take more control of your health by learning new skills to manage your health condition better on a day to day basis?

We know that for some people having a long term condition can affect their mood so we ask all our patients the following 2 questions.

Over the last 2 weeks how often have you had little interest or pleasure in doing things?
Over the last 2 weeks how often have you been feeling down, depressed or hopeless?
If you need a blood test form, please indicate how you would like to receive this. Please note the blood test form needs to be printed off.
Please remember to book this one week before your review appointment. (Do not specify with nurse as different practices use different clinicians - thank you).