NHS Health Check Questionnaire

If you have been advised by the surgery to complete a NHS Health Check Questionnaire, please use this form.

NHS Health Check Questionnaire

NHS Health Check Questionnaire

Patient Details

Please use date format: DD/MM/YYYY

Do you give consent for us to share information with Public Health? *

Smoking

Smoking status:

Height and Weight

Blood Pressure

Diet

What sort of diet do you have?
Do you eat 5 portions of fruit and vegetables a day?

Exercise

How much exercise do you get?

Family History

Do you have a family history of any of the following?

Diabetes Type 1:
Diabetes Type 2:
Cardiovascular Disease (ie. Heart attack, angina, stroke):
Hypertension:
High Cholesterol:
Cancer:
Other significant disease:

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

If you would prefer not to have a health check, please let us know and then submit this form: *
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