Long Term Conditions Review

If you have been invited to complete a Long Term Conditions review please use this form. This will help us gain an understanding of how you are managing with the conditions you have.

We review patients long term conditions annually. For more information please see our Long Term Conditions page.

Long Term Conditions Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Medication Review

Do you have any concerns or side effects from your medication? *
Do you know when and how to take your medication? *

Please speak to a Pharmacist or a GP to discuss when and how you should take your medication.

Are you happy for the doctor to update your medication review date now? *

Smoking

Smoking status: *

Please choose at least one of the options for what you mainly smoke.

Please choose at least one of the options for what you mainly smoked.

Please select all that apply:

Smoker

How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like help to give up smoking? *

Ex Smoker

How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

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 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 from you because of your drinking? *
How often during the last year have you needed an alcoholic 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 you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Patient Activation Measure

Would you like to help give us some insights on how to best help you look after your conditions? *

Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally. There are no right or wrong answers, just what is true for you. If the statement does not apply to you, select N/A.

I am the person who is responsible for taking care of my health: *
Taking an active role in my own health care is the most important thing that affects my health: *
I am confident I can help prevent or reduce problems associated with my health: *
I know what each of my prescribed medications do: *
I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself: *
I am confident that I can tell a doctor or nurse concerns I have even when he or she does not as: *
I am confident that I can carry out medical treatments I may need to do at home: *
I understand my health problems and what causes them: *
I know what treatments are available for my health problems: *
I have been able to maintain lifestyle changes, like healthy eating or exercising: *
I know how to prevent problems with my health: *
I am confident I can work out solutions when new problems arise with my health: *
I am confident that I can maintain lifestyle changes, like healthy eating and exercising, even during times of stress: *

Your Blood Pressure

Do you have a home blood pressure monitor? *

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

Please see guidance available on Taking Your Blood Pressure At Home.

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
/
Overall Average (All readings)
/

Asthma

Do you have asthma? *

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? *

If your score is less than 20:

Off target

Your asthma may not have been controlled during the past 4 weeks.

Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control.

If your score is between 20 and 24:

On target

Your asthma appears to have been reasonably well controlled during the past 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

If your score is 25+:

Well done

Your asthma appears to have been under control over the last 4 weeks.

However, if you are experiencing symptoms your Doctor or Nurse may be able to help you.

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

Please let us know that you have watched and understood the video(s): *

Hypothyroid

Do you have thyroid problems? *

Hypothyroid Self Assessment

If it is less than 60 or above 80 when resting please discuss this with your doctor
Change in Weight:
Have you had your blood tested for thyroid in the last 9 months? *

COPD

Do you have COPD? *

Assessment

Example: 0 being 'I never cough' and 5 being 'I cough all the time'

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 despite 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

Breathlessness

Please rate your level of breathlessness: *
*