NHS Health Check

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

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.


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?


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).