Online Hypertension Questionnaire Hypertension Questionnaire Details Full Name * Date of Birth * Date * Email Address * Physical Activity Physical Activity Involved In Work * Not in employment Much of time sitting day-to-day Most of time sitting or walking but no physical intense effort involved Work involves definite physical effort including handling of heavy objects and use of tools Work involves vigorous physical activity including handling of very heavy objects During the last week, how many hours did you spend on each of the following activities? Physical exercise such as swimming or jogging? * ... None Some but less than 1 hour 1-3 hours 3+ hours Cycling, including cycling to work and in leisure time? * ... None Some but less than 1 hour 1-3 hours 3+ hours Walking, including walking to work and in leisure time? * ... None Some but less than 1 hour 1-3 hours 3+ hours Housework/Childcare * ... None Some but less than 1 hour 1-3 hours 3+ hours Gardening/DIY * ... None Some but less than 1 hour 1-3 hours 3+ hours How would you describe your walking pace? * Slow (less than 3 mph) Steady average pace Brisk Smoker Status * Non-smoker Current smoker Ex-smoker How many per day? * How long have you stopped? * Family History Is there a family history of coronary heart disease in a first-degree relative under 60 years? * Yes No If so, please select who * Mother Father Sister Brother Alcohol Consumption How many units do you typically drink a week? * For more information on lifestyle advice please visit NHS Choices website www.nhs.uk/livewell or call in at reception for a leaflet Please remember we accept your home blood pressure readings - email them to info@gp-L81019.nhs.uk. reCAPTCHA Submit
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