NHS Health Check

Height and Weight

If you are overweight would you be interested in a referral to:
It is important to maintain a healthy weight, exercise regularly where possible, maintain alcohol consumption within the national guidance of 14 units a week and eat a balanced diet with fruit and vegetables. *
Please select the most appropriate answer:

BP: Please complete this if you have a home blood pressure machine

If you do not have a home blood pressure machine, please come into the surgery and use the machine in reception. Please make a note of this reading and complete this form.

Smoking

What is your current Smoking Status?
Would you like help to give up smoking?

Physical Activity

Physical activity involved at work:
Hours in the last week spent doing physical exercise:
Hours spent in the last week cycling:
Hours spent in the last week walking:
Hours spent in the last week on housework or childcare:
Hours spent in the last week doing gardening or DIY:
Usual level of walking pace:
Would you like referral to a physical activity exercise programme?

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? *
Alcohol: Suggested maximum 14 units a week. If you regularly drink as much as 14 units per week, it’s best to spread your drinking evenly over three or more days. *

Family History

Please select:

Carers Assessment

Are you currently a carer?
Would you like some assistance as your role as a carer?
Please select:

Memory Assessment

Do you or others have any concerns about your memory?

Self Management

Would you like a referral to a programme which aims to help you take more control of your health by learning new skills to manage your health condition better on a day to day basis?

We know that for some people having a long term condition can affect their mood so we ask all our patients the following 2 questions.

Over the last 2 weeks how often have you had little interest or pleasure in doing things?
Over the last 2 weeks how often have you been feeling down, depressed or hopeless?
To complete your NHS health check, a blood test is required to look at your cholesterol and sugar levels. Please indicate how you would like to receive your blood form:
Please remember to book this one week before your review appointment. (Do not specify with nurse as different practices use different clinicians – thank you).