NHS Health Check

If you have been advised by the surgery to submit an NHS health check questionnaire, please use this form.

Please complete what you can. The clinician may go over some of the following question areas again during your health check appointment. Any answers from the questions below that you can complete will help them. If you are unsure of any sections or have answers that do not have an option, don’t worry as the clinician will be able to go over these during your appointment.

NHS Health Check

NHS Health Checks are free for anyone aged between 40 and 74 years of age and does not already have a pre-existing condition. Patients can have a check once every 5 years. It can tell you whether you’re at higher risk of getting certain health problems, such as heart disease, diabetes, kidney disease, stroke and dementia.

Details

Name

DrMissMrMrsMsProf.Rev. Prefix First Last

Date of Birth

Day

Month

Year

Contact Number

Email

Enter Email Confirm Email

Blood Pressure

If you have a blood pressure monitor at home, please provide a couple of readings below or have them to hand when you speak to the clinician.

Systolic "Higher"

Diastolic "Lower"

Heart Rate

 

Add Remove

Alcohol Consumption

This is one unit of alcohol:

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

How many units of alcohol do you have per week?

How often do you have a drink containing alcohol?

NeverMonthly or less2-4 times per month2-3 times per week4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking?

1-23-45-67-910+

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?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Smoking

Smoking Status

SmokerEx SmokerNever Smoked

Weight, Diet and Physical Activity

Height:

Weight:

Waist circumference:

Exercise:

Exercises regularlyGets little exerciseGets no exercise

Diet:

GoodAveragePoor