Who requested this test?

• A Clinician at the surgery (GP/Advanced Nurse Practitioner/Nurse)
• My Hospital Consultant
• As part of my routine blood monitoring (due to medication)

Is there anything you'd like to let us know about the reading you are submitting?

• No
• I have noticed my readings are higher than normal
• I have noticed my readings are lower than normal
• Other

Do you smoke?

• No I have never smoked
• No but I used to smoke
• Yes - less than 5 cigarettes a day
• Yes - 5 to 10 cigarettes a day
• Yes between 11 and 20 cigarettes a day
• Yes between 20 and 40 cigarettes a day
• More than 40 cigarettes a day

Do you know how much alcohol you drink each week

• Don't know
• 1-7 units per week
• 8-14 units per week
• 15-21 units per week
• 22-28 units per week
• 29-35 units per week
• 36-69 units per week
• more than 70 units per week