Health Questionnaire Please supply the following information so we can update your medical records. Health Questionnaire Forename Surname Date of Birth What is your smoking status? Smoker Ex Smoker Never smoked Would you like to be contacted by the stop smoking advisor from the surgery? Yes No Do you suffer with Asthma? Yes No Does your Asthma Limit your activities? Yes No Does your Asthma disturb your sleep? Yes No Do you suffer with daytime symptoms? Yes No If you have a home Blood Pressure monitor what is your latest reading? Submit