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NHS health check (pre-assessment)

NHS Health Check (Pre-assessment Questionnaire)
Registered patient

If you are not registered as a patient at Stow Surgery, please do not complete this form.

Please contact your usual GP surgery instead.

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? *

Alcohol consumption

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? *

Family Medical History

Has an immediate family member suffered from either a heart attack or angina under 60 years of age? (Your parents, brother or sister) *
Has an immediate family member been diagnosed with diabetes? (Your parents, brother or sister) *

Carers

Do you have someone who looks after you as a carer? *
Do you care for anyone else? (eg. elderly, handicapped, chronically ill, child with a disability) *

Please ask at reception for information about support for carers.