General Health Assessment Name First Last Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Named GP (if known) Optional Height Weight SmokingSmoking status: Smoker Ex smoker Never smoked How many cigarettes do you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Would you like to give up smoking? Yes No Please visit NHS Stop Smoking for more information about giving up smoking.Blood PressureSystolic "Higher": Diastolic "Lower": Heart Rate: Date of reading: Please use this date format: DD/MM/YYYY.
