CDM Review - RA - Clackmannan and Kincardine Medical Practice

CDM - Rheumatoid Arthritis (RA)

This form is used for your annual RA review. Please answer the questions and submit this form to us. This form will be reviewed by the Practice Nurse and she will only contact you if it is required.

Your Details

Name *

Date of Birth *

Mobile Phone Number

Home Phone Number

RA Review

Height *

Weight *

Do you smoke? *

Yes No

If you do smoke, how many do you smoke per day?

How many units of alcohol do you drink per week? *

Has a parent ever had a hip fracture? *

Yes No

Have you ever had a hip fracture? *

Yes No

Do you have a family history of heart disease diagnosed under the age of 60? *

Yes No

How do you rate this online form? *

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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Page last reviewed: 17 November 2020
Page created: 03 January 2024

CDM - Rheumatoid Arthritis (RA)

CDM - Rheumatoid Arthritis (RA)

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