NHS Health Check

Please complete this form prior to your NHS health check appointment.

NHS Health Check

Smoking Status

Smoking status: *
Would you be interested in giving up? *

Family History

Have any of your close relatives (parent/brother/sister/grandparent) had a history of heart disease? *
Have any of your close relatives (parent/brother/sister/grandparent) had a history of stroke? *

Physical Activity

Please tell us the type and amount of physical activity involved in your work: *

During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc.? *
Cycling, including cycling to work and during leisure time? *
Walking, including walking to work, shopping, for pleasure etc.? *
Housework or childcare? *
Gardening or DIY? *
How would you describe your usual walking pace? *

Alcohol

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 alcoholAmount 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? *

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *