NHS Health Check (Pre-assessment Questionnaire)

Patient Details

Please use date format DD/MM/YYYY
All responses will be sent this email address.

Ethnicity

It is important for us to know this as risks for some diseases change depending on your ethnicity.
What ethnic group are you from? *

Your Diet

On an average day, how many portions of fruit and vegetables do you eat? *
A portion is roughly a handful e.g. a medium apple or pear, 7 strawberries or cherry tomatoes, 2 satsumas, vegetables (not potatoes) or a glass of juice

Smoking

Smoking Status: *
How many do you smoker per day? *

Exercise

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 (please answer whether you are in employment or not):
Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout, etc. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *
Cycling (including cycling to work) and during leisure time. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *
Walking (including walking to work), shopping, etc. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *
Housework or childcare. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *
Gardening or DIY. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *
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 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? *