Pre-Appointment Questionnaire

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Personal Details

This form asks about questions relating to your long term condition, such as hypertension.

This questionnaire is for patients who have been asked to complete it by us, one of our team may have text you or phoned you to ask you to complete it.

  1. Following completion of the form our team will be in touch to arrange a blood test appointment.
  2. Finally a GP will review the information you give us and blood test results.
  3. We will let you know the outcome of this review by text, email, letter or telephone as appropriate.
Please double check you've entered the correct email address
Ethnicity
Medical History
Smoking Status
Your Blood Pressure

Please take your blood pressure sitting down. Do 3 readings at least 1 minute apart.
If you cannot measure your blood pressure at home please leave this blank. When you come in for your blood test, please come 10 minutes early so you can use the machine in our reception. Our patient services team will be able to assist you.

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading
Your pulse rate is the number of times your heart beats per minute
Other Details

If you cannot measure your height and weight at home please leave this blank. When you come in for your blood test, you can use the scale in our reception area. Our patient services team will be able to assist you.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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