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CDM
CDM - Structured Treatment Program
Personal Information
Name
*
Surname
*
Email
*
DOB
*
PPS No.
*
Current Height (cm / feet):
*
Current Weight (Kg / stones):
*
Waist Circumference (cm):
*
Medical Conditions
1. Please select your known condition(s):
Asthma
Atrial Fibrillation
COPD
Gestational Diabetes
Heart Failure
Hypertension
Ischaemic Heart Disease
Pre-eclampsia
Stroke / TIA
Type 2 Diabetes
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
Is your COVID vaccine status up to date?
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
13. In the last 6 months due to chronic condition(s) You:
a) Attended emergency (not admitted)
b) Were admitted to hospital
c) Treated with antibiotic/steroids
Submit