Long Term Condition Review Long Term Condition Review Name First Last Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Named GP (if known) OptionalSmokingSmoking status: Current Smoker Ex Smoker Never Smoked Passive Smoker Vape/E-Cigarette 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 Blood PressureSystolic "Higher":Diastolic "Lower":Heart Rate:Date of reading:Please use this date format: DD/MM/YYYY.BMIHeightin metersWeightin kilogramsAlcohol ConsumptionHow often do you have a drink containing alcohol? Never Monthly or less 2 – 4 times per month 2 – 3 times per week 4 + times per week How many units of alcohol do you drink on a typical day when you are drinking? 1 – 2 3 – 4 5 – 6 7 – 9 10+ How often have you had 6 or more units (if femlae) or 8 or more (if male) on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily
