Informed Dissent
If you have received an invitation letter to attend for an annual review but do not wish to attend please read and complete the form below.
It is strongly recommend that any person with a long term health condition should receive regular care and follow up. However we understand that some patients may not want to attend for an annual review of their health condition(s).
If you do not wish to attend for your review we would be grateful if you could complete this form.
If you decide you do not wish to attend for a review at this time you are always welcome to make an appointment at a later date.
If you DO NOT want to attend for your annual review please complete the form below.
Your Name:
Your Date of Birth:
Your Email Address:
Please note you will receive an invitation for review next year
To keep our records up to date please complete the health questionnaire below
Your Smoking Status - Are you a:
IF you are an EX-SMOKER when did you quit:
IF you are an CURRENT SMOKER how much do you smoke per day?:
What is you average alcohol intake (in units) per week?
1 Standard
Glass of wine is roughly 2.2 Units
1 standard
PINT of beer is roughly 2.8 Units
1 single 40% spirit is
roughly 1 Unit
Well-being Screening
During
the last month, have you often been bothered by feeling down, depressed or
hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?