Prevention Programme Pre-Appointment Form

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Form Received

Thank you. Your health update has been sent to Kinsealy Medical Centre.
Our team will review it and ring you to book your appointment.

If you have any questions, contact us at kinsealymedicalcentre@protonmail.com
or call (01) 845 2500.

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Fasting Required — Please Read Before Your Appointment

You must fast from midnight the night before your appointment. This means no food or drink except plain water from midnight onwards. Fasting is needed for accurate blood results (cholesterol, triglycerides, glucose).

Medications: Continue all regular medications as normal with a small sip of water.

Before You Begin — What You'll Need

To get the most from this form, please have the following to hand if possible:

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Weight scales — to enter your weight in Section 4.

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A measuring tape — to measure your waist in Section 4.

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A home blood pressure machine — if you have one, please take a few readings over several mornings and note your average. Home readings are often more accurate than surgery readings because some people's blood pressure rises when they visit a doctor or nurse — known as white coat hypertension. A home average gives us a truer picture of your usual blood pressure.
If you are declining the 24-hour BP monitor (ABPM) in Section 7, a home reading is helpful for your nurse to review.

Not sure if you should be completing this form or the CDM form, or unsure which programme you're on? Email kinsealymedicalcentre@protonmail.com and we'll check for you.

1 — Patient Details

Full Name *

Please enter your full name.

Date of Birth *

Required.

Phone Number *

Required.

Email Address *

Please enter a valid email address.

2 — Your Health & Lifestyle

How many days per week do you do physical activity or exercise (at least 30 minutes)? *

Required.

Any concerns about your diet you would like to discuss? (optional)

Do you check your blood pressure at home?

Yes

Average reading over the past week (e.g. 128/76)

Any new family history of heart disease, stroke, or diabetes since your last visit? *

Required.

🧪 Please bring a urine sample to your appointment. A small amount of urine (in a clean container) is needed to check your kidney health as part of your review. You can collect this first thing in the morning on the day of your appointment.

I confirm I will bring a urine sample to my appointment.

3 — General Health Update

Has your overall health changed since your last visit? *

Please briefly describe the changes

Any hospital admissions or A&E visits since your last appointment? *

Please briefly describe what happened and which hospital

Any new diagnoses or new hospital specialists since your last visit? *

Please give details

Smoking status *

Approximately how many cigarettes per day?

Would you like support to stop smoking?

Do you drink alcohol? *

Approximate weekly intake (units)

1 unit = half a pint of beer, a small (100ml) glass of wine, or a single (25ml) spirit measure.

Has your alcohol intake changed recently?

Any issues with your medications? *

Health and Well-being — How would you describe this? *

My Health Goals (optional)

4 — Physical Measurements (optional)

If you are able to weigh yourself and measure your waist at home, please complete the fields below. Both are entirely optional — we will take these measurements at your appointment if you prefer.

Weight (optional)

kg — Weigh yourself in the morning before eating, with light clothing and no shoes.

Waist Circumference (optional)

cm — Measured at the midpoint between your lowest rib and hip bone, at the end of a gentle exhale.

5 — Medications & Allergies

Please bring your medication list or tablets to your appointment. If you have any new medications from a hospital, specialist, or other doctor since your last visit, please list them below.

Any new medications added since your last visit? *

6 — Blood Tests

Good news — your Prevention Programme bloods are free of charge. On the day, we carry out the standard blood tests for your review (cholesterol, glucose, and other relevant tests) — these are fully covered, nothing for you to pay.

If you also need bloods ordered by your GP (e.g. your annual bloods) or by a hospital consultant, these fall outside the scheme and are charged separately — select below and let us know which tests are needed.

Do you also need any bloods outside your Prevention Programme review? *

No — I'm happy with the bloods covered under my Prevention Programme review

Yes — bloods ordered by my GP, or my annual bloods

Yes — bloods ordered by a hospital consultant

Please list the tests your GP has requested

Charged at our standard GP-ordered bloods fee of €40 — see fees ↗. Payable on the day at reception.

Please list the tests your consultant has requested

Charged at our standard consultant-ordered bloods fee of €60 — see fees ↗. Payable on the day at reception.

Please make a selection.

7 — 24-Hour Blood Pressure Monitor (ABPM)

What is an ABPM? The ABPM is a small device worn on your upper arm for 24 hours. It automatically checks your blood pressure every 30 minutes during the day and every hour at night, giving a much more accurate picture than a single surgery reading.

Your nurse may recommend an ABPM at your appointment based on your blood pressure reading and overall cardiovascular risk profile. If you are unsure whether this applies to you, your nurse will advise you on the day.

📋 Device Responsibility Agreement

By entering your full name below and ticking the box, you confirm you have read and understood the care instructions above and that you accept responsibility for the ABPM device for the duration of the monitoring period. Any damage, loss, or failure to return the device may result in a replacement charge being applied to your account.

Full Name — Electronic Signature *

Entering your full name serves as your electronic signature for this responsibility agreement.

Please enter your full name to complete the responsibility agreement.

I confirm I have read the ABPM care instructions above and I accept full responsibility for the device while it is in my care. I understand that damage, loss, or failure to return the device may result in a replacement charge.

8 — What to Expect on the Day

🛡️ Your Prevention Programme Appointment

Arrive fasting — no food or drink (except water) from midnight the night before. Continue all regular medications as normal.

Check in at reception — let staff know you are here for your Prevention Programme review.

Nurse / Phlebotomist — will take blood samples (cholesterol, glucose, and other relevant tests), check your blood pressure, weight, and height, and fit a 24-hour blood pressure monitor (ABPM) if required. This may take 20–30 minutes.

Doctor review — your GP will review your results and discuss any lifestyle or medication recommendations. If follow-up is needed, they will contact you.

Your script — a 12-month prescription will be issued.

9 — Data Consent & Confirmation