Cumberland House Annual Review Questionnaire

Please only complete this questionnaire if you have received a request from us to do so. Thank you.

Please complete as many of the questions below as you can. Questions marked with a star must be completed. Once completed, please click on the “Submit” button at the bottom of the form to send your answers to us.

1. Your Details
Do you consent to us sending you texts relating to your health?
YesNo
2. Please enter your height and weight, and indicate if you are using metric or imperial measurements.
m/cmft/in
kgst/lb
3. Your smoking status:
Never SmokedEx-SmokerCurrent Smoker
4. Your weekly alcohol consumption: (1 unit = ½ pint of beer or a small glass of wine)
0 Units1-7 Units8 - 14 Units15 - 21 Units22 - 27 Units28+ Units
5. Hypertension

If you have a diagnosis of high blood pressure or are taking medication to control your blood pressure, please answer the following questions.

Are you taking your medications as they appear on your prescription?
YesNo
Do you have any concerns about any of your medicines?
Please submit your last 3 home blood pressure readings.
6. Asthma

If you have a diagnosis of asthma or are taking any asthma medication, please answer the following questions.

Are you taking your medications as they appear on your prescription?
YesNo
Is your asthma well controlled?
7. Epilepsy

If you have a diagnosis of epilepsy or are taking any related medication, please answer the following questions.

Are you taking your medications as they appear on your prescription?
YesNo
Do you have any concerns or side effects from your medicines?
Do you see a hospital specialist for your epilepsy?
YesNo
When was your last seizure?
Do you hold a driving licence?
YesNo
8. Please use this space for any additional information you wish to provide.

For an appointment or clinical advice, contact your practice