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

Patient Details

Are you completing this form on behalf of: *

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: *
e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Smoking

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

Alcohol Consumption

Units per week

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 a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected of you because of drinking? *
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because of your drinking? *
Have you or someone else been injured because of your drinking? *
Has a relative, friend, doctor or other health care worker been concerned about the drinking or suggested you cut down? *

Your Blood Pressure

Please use this date format: DD/MM/YYYY.
/
Are you taking an over the counter aspirin?

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 Hypertension? *
Do you have mental health issues? *

Mental Health

Do you have a family history of mental health?
Employment status:
Do you have dependents?
How would you describe your nutritional status?
Do you require dietary or weight management advice?
What is your lifestyle activity status?
Mood:
Sleep:
Self-harm:
Suicide risk:
Do you use recreational drugs?
Have you been referred to a drug worker?
Would you like to be referred to a drug worker?
Do you have a history of misusing drugs/substances?
Do you require help or support with substance abuse?
Are you sexually active?
Do you experience thought disorders?
Would you like a nurse to contact you for a follow up consultation?
How would you prefer this follow up consultation?

Do you have a learning disability? *

Learning Disability

Certain syndromes causing learning disabilities are associated with increased morbidity, and so for this reason, it is important to record the following:

What is the cause of your learning disability?
Have genetic investigations been done?
Do you have a hearing problem?
Select your hearing problem:
Have you been seen by an audiologist?
Do you have a visual problem?
Please select your visual problem:
Have you been seen by an optometrist?
Guidance suggests patients should be seen by an optometrist every 2 years.
Do you have a physical disability?
Please select your disability:
Do you have a carer?
Please select the relevant answer:
Is a social worker involved?
Are you under the care of social services?
Are other agencies involved?
Please select the relevant answer(s):

Only record third party information if you have consent.

What are your current living arrangements?
Are you housebound?
Do you have mental capacity to give consent for assessment?
Do you have a speech problem?
Please select the relevant answer(s):
Do you already see the speech therapist?
Would you like to be referred to the speech therapist?
Do you use communication aids?
Is an interpreter needed?
Do you require a communication partner?
Do you use Makaton sign language?
Are you registered with a dentist?
Are you up to date with immunisations?
Have you declined any immunisations?
What is your employment status?
Mobility:
Feeding:
Swallowing:
Dressing:
Drinking:
Bathing:
Urine continence:
Bowel continence:
Toileting:
Diet:
Exercise:
Mood:
Sleep:
Self-harm:
Suicide risk:
Any loss of skills noticed?
Change in behavior noticed?
dementia concerns?
Do you use recreational drugs?
Have you been referred to a drug worker?
Would you like to be referred to a drug worker?
Are you aware about the bowel cancer screening programme?
If you are female, do you do your breast examination?
If you are female, have you attended a mammogram screening?
If you are female, have you ever had a cervical screening?
If you are male, do you do your testicular examination?
If you are male, have you had an Abdominal Aortic Aneurysm screening offered?
Are you sexually active?
If you are aged between 14 and 17 years, what is your education status?
Would you like the nurse to contact you for a follow up consultation?
How would you prefer this follow up consultation?

Do you have dementia? *

Dementia

Does the next of kin have Lasting Power of Attorney (LPA)?
Have you seen the original document?
Does anyone else have Lasting Power of Attorney (LPA)?
Have you seen the original document?

Please give as much information as possible and document any concerns that you might have.

Mobility:
Apetite:
Hearing:
Continence:
Vision:
Medical administration:
Nutrition:
Personal care:
Are there any problems with compliance?
Mood:
Feels lost:
Behavior:
Patient awareness:
Sleep pattern:
Hallucinations:
Abusive behavior:
Agitation:
Are there any aspects of this review that requires a GP review?
Would you like the nurse to contact you for a follow up consultation?
How would you prefer this follow up consultation?

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? *

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?
Have you received an asthma action plan?
Are you happy with this plan?

Please continue to seek support if you have any changes in control.

Would you like to receive a plan?
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?
For more help with your inhaler technique, you can visit the Asthma UK website.

Do you have COPD? *

COPD

Over the last year, have you had any hospital admissions related to your COPD or required antibiotic or steroid treatment?
Have you ever been issued with a rescue pack or told by a clinician you require one?
If you use inhalers, do you feel they are helping with your symptoms and that you are happy with how to use them?
Do you measure your oxygen saturations at home? If yes, are you on home oxygen therapy?

The Pulmonary Rehabilitation Programme can be offered virtually to patients at present to help with managing all COPD/lung related symptoms and is run by the specialist rehabilitation respiratory team. Please see link here for more information: www.norfolkcommunityhealthandcare.nhs.uk/pulmonary-rehabilitation

Would you be interested in the pulmonary rehabilitation programme?

A referral will be made by clinicians and will be contacted in due course depending on availability.

Do you feel you are overall happy with your current management of your condition and with your medicines to help with your symptoms?

A telephone appointment will be offered to you.

Before submitting your annual health review

*