Annual Chronic Kidney Disease Review

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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