Long Term Conditions Annual Review Form

If you have been asked to complete a Long Term Conditions Annual Review please complete this form.

Long Term Condition Annual Review

Appointment required (tick all that apply):
Have you been contacted by the practice to book this appointment?

BMI

Please provide your height in metres (e.g. 1.75)
Please provide your weight in Kilograms (e.g. 75.6)

Smoking Status

Please select your smoking status:

Alcohol Consumption

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 alcoholAmount 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? *

Mental Health and Wellbeing

Living with long term conditions can sometimes be tough. There may be many problems and hassles concerning health issues and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Listed below are 2 potential problem areas that people may experience. Consider the degree to which each of the 2 items may have distressed or bothered you during the past month and select the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would select "1." If it is very bothersome to you, you might select "6."

If you are struggling with your mental health or would like to find mental health services, please visit our Wellbeing Centre.

Feeling

Please indicate the level of the problem by using the 1-6 scale:

Feeling that I am often failing with my health management:
1-2 = Not a problem / 3-4 = Moderate problem / 5-6 = Serious problem
Feeling overwhelmed by the demands of living with a long term condition:
1-2 = Not a problem / 3-4 = Moderate problem / 5-6 = Serious problem

Your Priority Areas

These are some things that people sometimes want to talk about. Please select any that are important to you:

More information

Is there anything specific you would like to discuss at your review?