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Dedridge Medical Group > Your Record > Chronic Disease Management > Peripheral Vascular Disease

Peripheral Vascular Disease

Please complete this form if you have been asked to do so as part of your annual monitoring. If you do not have access to a home BP monitor, we have a self check BP machine in the waiting area which you may use without an appointment.

Please also remember to book an appointment for bloods if you have not had any within the last year (including glucose and lipids).

For more information on your condition and recommended lifestyle adjustments please see here.

Peripheral Vascular Disease Review

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

What is your blood pressure ? *

What is your weight? *

Do you smoke? *

Yes

Please see review the information available on the benefits of quitting smoking to you and those around you. Find the support you might need to make your quit attempt a success on NHS Inform – Stop Smoking.

How active are you? *

Do you have any symptoms of concern relating to your vascular disease?

Are you experiencing any problems with your medication? *

Yes

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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