NHS Health Check

Have you received an invitation (letter or text) to book this review? *

Yes

No

You must have received an invitation to book a NHS Health Check in order to submit this form.

Patient Details

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Telephone Number:

Email Address: *

Exercise

1. Physical activity at work

Please tell us the type and amount of physical activity involved in your work, tick the box that is most relevant to you:

I am not in employment (retired, retired for health reasons, unemployed, full-time carer etc)

I spend most of my time at work sitting (office work etc)

I spend most of my time at working standing/walking, it does not include intense physical effort (Shop assistant, hairdresser, security guard etc)

My work involves definite physical effort including handling of heavy objects/use of tools (plumber, electrician, cleaner, nurse)

My work involves vigorous physical activity (scaffolder, refuse collector, personal trainer)

2. Physical Exercise

During the last week, how many hours approximately did you spend on each of the following activites? Please state amount in each box:

Physical exercise (swimming, jogging, aerobics, football, tennis, gym workout etc):

Cycling, including cycling to work and during leisure time:

Walking, including walking to work, shopping and for pleasure:

Housework/Childcare:

Gardening/DIY:

Diet

How would you say you diet is from Good, Average, or Poor?

Good Diet (3 meals a day, including 5 servings of fruits and vegatables, plenty of water)

Average

Poor (mainly consistening of fast foods, no fruit or vegetables, and no water)

Smoking

Do you currently smoke tobacco?

Yes

No

Do you currently smoke an e-cigeratte/vape?

Yes

No

Yes

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

No

Would you like support to stop smoking?

Yes

No

Have you smoked in the past?

Yes

No

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

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? *

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NHS Health Check

Patient Details

Exercise

1. Physical activity at work

2. Physical Exercise

Diet

Smoking

Yes

No

This is one unit of alcohol:

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

Annual Health Review