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Long term condition questionnaire

Long Term Condition Questionnaire

Your Blood Pressure

Please provide a blood pressure reading taken within the last 7 days.

Please use this date format: DD/MM/YYYY.

Family History

Does anyone in your immediate family over the age of 60 have a history of coronary heart disease (e.g., angina, heart failure, heart attack)?
Does anyone in your immediate family under the age of 60 have a history of coronary heart disease?
Do you or any immediate family members have Type 2 Diabetes?
Have you or any immediate family members ever had a stroke?

About You

For example, 1.75
In kg.

NHS exercise guidelines (opens in new tab)

Smoking Status

Do you currently smoke tobacco?
How many cigarettes do you typically smoke in a day?
Have you smoked in the past?
How many cigarettes did you smoke per day?
Do you use an e-cigarette/vape?

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Health and wellbeing

Please look at the following 4 statements and rate each statement between 1 – 5, depending on which is most appropriate for you.

1 = Strongly Disagree, 5 = Strongly Agree.

I understand that I am the person who is ultimately responsible for my health and wellbeing.
I have the ability to make changes to help improve my health and wellbeing.
I’m confident I know how to prevent problems with my health and what to do to improve it.
I want to improve my health and I will follow through on what is needed to do it.

Acknowledgment

Confirmation