Remote Annual Health Review

If you have been invited to submit a remote annual health review by the practice, please submit this form.

Remote Annual Health Review

Remote Annual Health Review

About You

This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.
Gender: *

Smoking

Have you ever smoked? *
Do you smoke now? *

Alcohol Consumption

Units per week

Annual Health Review

Do you have chronic heart disease? *
Have you suffered a stroke or mini stroke? *
Do you have chronic kidney disease? *
Do you have peripheral arterial disease? *
Do you have heart failure? *
Do you have atrial fibrillation? *
Do you have mental health issues? *
Do you have a learning disability? *
Do you have dementia? *
Do you have diabetes? *

Diabetes

Do you record your blood sugars?
Have you ever had a hypoglycemic event?
Are you aware of how to manage these?
Do you suffer from erectile dysfunction?
If possible, would you like any treatment to help with this problem?

Toe Touch Test

1st touch:
2nd touch:
3rd touch:
4th touch:
5th touch:
6th touch:

Do you have epilepsy? *

Epilepsy Review

How often do you have an epileptic fit?
Are you currently on treatment for epilepsy?
Does your epilepsy mean having to take time off work or school?
What is your current driving status?
Are the DVLA aware of your condition?
If you are a woman of child-bearing age, would you like us to send you some information regarding contraception, pregnancy and how this is affected by your epilepsy medication?

Do you have asthma? *

Asthma Review

In the last month have you had difficulty sleeping due to your asthma (including cough)? *
Have you had your usual asthma symptoms (e.g., cough, wheeze, chest tightness, shortness of breath) during the day? *
Has your asthma interfered with your usual daily activities (e.g., school, work, housework)? *
Have you ever had your peak flow measured at the surgery? *
Do you know your best PEFR value?
Please provide value in ml/min.

Asthma Control Score

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home? *
During the past 4 weeks, how often have you had shortness of breath? *
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning? *
During the past 4 weeks, how often have you used your reliever inhaler (usually blue)? *
How would you rate your asthma control during the past 4 weeks? *

Score Explanation

Additional Questions

Since your last review, have you needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of your asthma?
Since your last review, have you needed a course of steroid tablets to get your asthma under control?
Did you have a flu vaccination last flu season?
Please select the types of inhalers that you use:

Please watch these short video(s) on how to use your inhalers

Have you watched and understood the video(s)? *
Are you happy with your inhaler technique? *
Would you like further explanation from a practice nurse?

Do you have COPD? *

COPD

Coughing

I never cough
I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all
My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all
My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless
When I walk up a hill or one flight of stairs I am very breathless

Activities

I am not limited doing any activities at home
I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition
I am not at all confident leaving my home because of my lung condition

Sleep

I sleep soundly
I don't sleep soundly because of my lung condition

Energy

I have lots of energy
I have no energy at all

Your Blood Pressure

Please provide a minimum of one blood pressure reading, up to a maximum of seven.

Day 1

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

/
Evening Measurement
/

Before submitting your annual health review

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