Annual Review Appointment - no thank you form

This form is to say - NO THANK YOU - to an Annual Review Appointment (this year)

If you have received an invitation for an Annual Review this year - then we would recommend that you come in to the surgery as it can be very important to help you stay well.

If however, you are really sure that you do not wish to have an Annual Review this year then please can you fill in the form below. We will then make a note and will not invite you again until next year.

The NHS requires every surgery to invite patients for annual reviews every year as people who come are more likely to stay well for longer. We are required to send out several reminders to come in which costs us a huge amount of money and time that we would be better putting directly towards patient care. It is really important to reply to all our requests if you really do not wish to have an appointment - so thank you for helping us by completing this form.

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

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* 4. I have been recommended to have an annual review appointment by my GP.
However, I have decided that I do not wish to have one this year.

Please select those conditions that apply to you from the list below to say no thank you.

Asthma

Blood Pressure

COPD

COPD - Spirometry

Dementia

Diabetes

Heart Problems

Mental Health

Rheumatoid Arthritis

Stroke

Other (please specify)

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* 5. Optional - is there a particular reason why you prefer not to have a review this year?

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* 6. While you are here - please can you answer a couple questions about yourself that will help us keep your record up to date - this will really help us!

How many units of alcohol do you drink each week?

1 unit = a very small glass of wine or 1 shot or half a pint of lager
So if you have half a bottle of wine 2 x per week that would be about 10 - 12 units during the week
If you have 6 pints over a week - that is about 12 units for standard beer or 18 units for strong beers or lagers
For more information on units per week see NHS Choices (opens in a new window)

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* 7. Do you smoke at the moment?

Yes - currently a smoker

No - not currently a smoker

No - never smoked

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* 8. If you answered yes - currently a smoker above

How many cigarettes per day

How many roll ups per day

How many cigars per day

How many pipes smoked per day

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

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* 4. I have been recommended to have an annual review appointment by my GP.However, I have decided that I do not wish to have one this year.Please select those conditions that apply to you from the list below to say no thank you.

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* 5. Optional - is there a particular reason why you prefer not to have a review this year?

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* 7. Do you smoke at the moment?

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* 8. If you answered yes - currently a smoker above

* 4. I have been recommended to have an annual review appointment by my GP.
However, I have decided that I do not wish to have one this year.

Please select those conditions that apply to you from the list below to say no thank you.