NHS Health Check Questionnaire

The Government have asked us to offer a free NHS Health Check to people who are aged between 40 and 75 years with no existing history of diabetes, heart disease, high blood pressure, stroke or chronic kidney disease.

Most people who qualify for this free health will receive an invitation by letter although those who are in receipt of regular medication will be offered the health check at the time of their medication review, usually during the month of their birthday. Some people will be invited opportunistically should they visit the practice for some other reason and a health check is indicated.

Please be as honest as possible to help us to help you.

NHS Health Check Questionnaire

NHS Health Check Questionnaire

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Gender *
Any responses we send will go to this email address.

Ethnicity

Please specify the ethnic group you consider you belong to:

Smoking Status

Smoking Status:
Do you smoke any of the following

Alcohol Consumption

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?

Physical Activity and Diet

Your Family History

Did / does any close relative (parents or siblings) have any of these diseases?
Do you have any 1st degree relatives with Diabetes also diagnosed with angina, stroke and/or heart attack when they were aged less than 55 years (for males) or 65 years (for females)

Cancer

Has any close relative been diagnosed with cancer?

Early Detection and Support

Have you ever been told by a doctor that you have high blood pressure?
Have you ever been told by a doctor that you have high blood sugar (eg, in a health examination, during an illness or during pregnancy?

General Questions

Tick for Yes
Men only
Women only

Carers

If you care for someone in your family, a friend or a neighbour who could not manage without your help then you are a Care. The person you care for may require your help due to frality, illness, learning or physical disability, sensory impairment, mental illness or addiction.
Tick for if true