NHS Health Check

If you have been advised by the surgery to do so, please submit this form.

NHS Health Check

NHS Health Check

Gender: *

Ethnicity

Please specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?

Body Mass Index

e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Smoking Status

Do you smoke? *
How many do you smoke per day? *

Getting expert support and advice from your local stop smoking service will mean you are four times more likely to succeed at quitting smoking than going at it alone.

If you would like help or advice to quit smoking, please visit our Wellbeing Centre.

Alcohol

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? *

Physical Activity: GPPAQ

1. Please tell us the type and amount of physical activity involved in your work: *

2. During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc.? *
Cycling, including cycling to work and during leisure time? *
Walking, including walking to work, shopping, for pleasure etc.? *
Housework or childcare? *
Gardening or DIY? *
3. How would you describe your usual walking pace? *

Family History

Have any of your immediate relatives had any of the following diagnosed under the age of 60:

Additional Information

Would you be interested in finding more information on healthy lifestyle choices/ weight loss/ exercise?