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. Contact Details
    Do you consent to us sending you texts relating to your health?
    Do you have a smart phone?


    2. About You
    Height / Weight:
    Smoking Status:
    Never SmokedEx-SmokerCurrent SmokerElectronic Cigarette/ Vape User
    How much do you smoke per day?
    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


    3. Blood Pressure

    To enable us to review your blood pressure safely during the pandemic, please purchase a home blood pressure monitor, available from online retailers or your pharmacy. Arm monitors are much more accurate than wrist ones.

    If you have any of the following conditions, we need up to date blood pressure readings in order to complete your review:
    • High Blood Pressure
    • Atrial Fibrillation
    • Diabetes
    • Heart Disease
    • Heart Failure
    • A Mental Health Disorder
    • Peripheral Arterial Disease
    • A history of Stroke or TIA
    Please provide your last three blood pressure readings


    4. Medication
    Have you stopped taking any of your prescribed medications? Are you experiencing any problems with any of your medications?


    5. Other Information
    Please use this space for any other information you wish to provide.

    Thank you for completing the annual review form.

    For an appointment or clinical advice, contact your practice