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) Optional SmokingSmoking 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
