Annual Chronic Kidney Disease Review

If you have been advised by the surgery to submit an annual chronic kidney disease review, please use this form.

Annual Chronic Kidney Disease Review
Which surgery are you registered with? *

Section

About You

eg. 1.75
eg. 60.6

Smoking

Smoking status: *

Smoker

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

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

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

Activity Levels

Please indicate which option best describes your activity levels:

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.

Please use date format: DD/MM/YYYY
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