Annual Chronic Kidney Disease Review | Russell Street Group Practice

Which surgery are you registered with? *

Russell Street Surgery

Burghfield Health Centre

Coley Park Surgery

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About you

Your First Name(s): *

First Name(s) as appears on your passport.

Your Last Name: *

Last Name(s) as appears on your passport.

Your Date of Birth: *

Your date of birth is required to verify your identity.

Sex: *

Male

Female

Other

As on your medical record.

Your Phone Number: *

The practice may use this number to contact you about your request.

Your Email: *

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below

About You

Height (in Meters): *

eg. 1.75

Weight (in Kilograms): *

eg. 60.6

BMI:

Alcohol Consumption (units per week):

Smoking

Smoking status: *

Smoker

Never smoked

Ex smoker

Smoker

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars 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

Ex Smoker

Rollups - How many grams of tobacco did you smoke per week? *

Pipe - How many grams of tobacco did you smoke per week? *

When did you quit smoking? *

Activity Levels

Please indicate which option best describes your activity levels:

Gets no exercise

Gets little exercise

Exercises regularly

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Systolic "Higher":

/

Diastolic "Lower":

Heart Rate: