NHS Health Check Questionnaire

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 Check

If you are human, leave this field blank.

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.

Section

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

Systolic "Higher"

/

Diastolic "Lower"

Heart Rate

Alcohol Consumption

This is one unit of alcohol:

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

Total units per week:

Total units per day:

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Smoking

Smoking status:

Smoker

Ex smoker

Never smoked

Refusal to give smoking status

Please select all that apply:

Trivial cigarette smoker (less than one cigarette/day)

Light cigarette smoker (1-9 cigs/day)

Moderate cigarette smoker (10-19 cigs/day)

Heavy cigarette smoker (20-39 cigs/day)

Very heavy cigarette smoker (40+ cigs/day)

Cigar smoker

Pipe smoker

User of electronic cigarette

Everybody knows that smoking is harmful to your health. Find out more about the benefits of giving up smoking and the support available.

Contact Smokefree Norfolk by calling 0800 0854113 or visit www.smokefreenorfolk.nhs.uk

Please select all that apply:

Ex cigarette smoker

Ex trivial cigarette smoker (<1/day)

Ex light cigarette smoker (1-9/day)

Ex moderate cigarette smoker (10-19/day)

Ex heavy cigarette smoker (20-39/day)

Ex very heavy cigarette smoker (40+/day)

Ex cigar smoker

Ex pipe smoker

Ex user of electronic cigarette

Weight, Diet and Physical Activity

Height:

Weight:

Waist circumference:

Diet type:

Normal diet

Vegan diet

Vegetarian diet

Pescatarian diet

Diet quality:

Diet good

Diet average

Diet poor

Exercise:

Exercises regularly

Gets little exercise

Gets no exercise

Additional Information

Occupation:

Family history (if known):

Family history of diabetes

Family history of heart disease under 60 years old

Family history of heart disease over 60 years old

Family history of hypercholesterolaemia

Ethnic group:

White British

Irish

Other White

Black

Caribbean

African

Other Black

Asian

Indian

Pakistani

Chinese

Other Asian

Mixed

White & Black Caribbean

White & African

White & Asian

Other Mixed

I do not wish to disclose

Other

Please specify:

Please note, your ethnicity will make a difference on some testing results.

Submit