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Haverhill Family Practice

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eConsult - Click here to request an appointment, help or advice
New Patients
Appointments
Prescriptions
Online Forms
Services
Patient Record
Health Advice [includes EASY READ]

Language
Home
Opening Hours
Online Services
Our Staff
Contact Us

CKD Review Form

Last Updated: 24/06/2020

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

CKD REVIEW

What is your weight?

What is your height?

If you have a home BP machine, what is your Blood Pressure?

What is your pulse rate?

Do you have a healthy diet?

Yes No

Do you participate in any form of exercise? If so, what do you do?

How many units of alcohol do you drink per week?

None

1-5

6-10

More than 10

What is your smoking status?

Never smoked

Current smoker

Ex-Smoker

If you currently smoke, how many cigarettes per day?

Do you have a carer?

Yes No

If Yes, please give Carers details. (Name and Telephone Number)

AFTER COMPLETING AND SUBMITTING THIS FORM, PLEASE MAKE AN APPOINTMENT TO HAVE A BLOOD TEST WITH ONE OF OUR HEALTHCARE ASSISTANTS (UNLESS YOU HAVE ALREADY BOOKED YOUR APPOINTMENT). PLEASE BRING WITH YOU A URINE SAMPLE.

FOLLOWING YOUR BLOOD TEST THE NURSE WILL CONTACT YOU FOR YOUR REVIEW.

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