Confidential pharmacy support

Patient lifestyle questionnaire

Tell our pharmacists about your needs so they can assess your request safely and recommend suitable next steps.

A few minutes

Help us understand your health needs

Fields marked with an asterisk are required.

Prototype form: your entries and selected file stay in this browser and are not sent to the pharmacy. To share health information securely, use the pharmacy’s linked service or contact the team. Read our Privacy Policy.

First name *Last name *Email *Phone number *

What is your typical daily diet like?Do you smoke, and would you like support to stop?How active are you during a typical week?What health information or support would you like from us?Do you have a long-term condition that requires regular medicine?Is there any regular medication you would like us to discuss with you? Medical history file (optional)I confirm that the information provided is accurate to the best of my knowledge.

Patient lifestyle questionnaire

Help us understand your health needs

Nominate Belsize Priory.