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Home » Forms » NHS healthcheck

NHS healthcheck

If you have received a letter from the surgery inviting you for a free NHS Health Check please use this form. We do need to know your height, weight and blood pressure. You can check these using home devices or they can be done at most gyms and some pharmacies. If you are still unable to access any of these, you will need to book a face to face appointment with a nurse.

NHS healthcheck

First name *

Last name *

Date of Birth *

Mobile Phone Number *

Email *

Your NHS Healthcheck

Blood pressure reading *

Pulse (beats per minute) *

This will either be shown on the BP machine or can be checked by counting the beats in 1 minute using the radial pulse.

Height (cms) *

Weight (kgs) *

Approximately how many units of alcohol do you consume each week? *

1 unit of alcohol is equal to a 25ml single measure of whisky, a third of a pint of beer or half a standard (175ml) glass of wine.

Approximately how long do you spend on physical activity each week? *

Inactive - Less than 30 minutes a week

Moderately active - Between 30 and 60 minutes a week

Active - Between 60 and 150 minutes a week

What type of exercise do you do if any? *

Smoking status *

Smoker

Ex smoker

Never smoked

How many do you smoke per day? *

25g of tobacco = 7 cigarettes

Would you be interested in receiving smoking cessation advice? *

Yes

When did you give up smoking? *

Do you have any concerns regarding your memory? *

Yes

Please specify *

Do you have a family history of the following?

Ischaemic heart disease *

Yes

Angina in 1st degree female relative <65yrs *

Yes

Angina in 1st degree male relative <55yrs *

Yes

Heart attack in 1st degree female relative <65yrs *

Yes

Heart attack in 1st degree male relative <55yrs *

Yes

Diabetes *

Yes

Raised Cholesterol *

Yes

Is there any other family history you think may be relevant?

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