CDM - Structured Treatment Program

Personal Information

Name*

Surname*

Email*

DOB *

PPS No.*

Current Height (cm / feet):*

Current Weight (Kg / stones):*

Waist Circumference (cm):*

Lifestyle & Habits

2. Do you smoke? *

Yes

No

3. Do you vape?

Yes

No

4. How often do you drink Alcohol?

5. Do you exercise? *

Yes

No

Vaccinations

6. Did you receive the flu vaccine last season? *

Yes

No

7. Have you received a pneumococcal vaccine?*

Yes

No

8. Did you receive the COVID vaccine? *

Yes

No

Tests & Hospitalizations

9. Have you ever had an ECG since the last visit?

Yes

No

10. Have you had spirometry since the last visit?

Yes

No

11. Diabetes related amputation (if applicable)

Yes

No

12. Have you had a blood test in the last 6 months?

Yes

No

Can't say