NHS Health Check

Please fill in this form if you require an NHS health check.

NHS Health Check

NHS Health Check

Section

Health Data

eg. 1.75
eg. 60.6

Blood Pressure Reading:

Have you ever smoked?
Do you smoke now?

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what's right for you. For more information visit: www.nhs.uk/quit-smoking

Tick which dietary option(s) applies to you:
How would you rate your exercise level:
Please tick all boxes that apply to your family history:
Are you a military veteran?

Dementia Screening

Dementia affects the way your brain normally works making it difficult to do every day activities, for example forgetting things or becoming confused.

Common symptoms of dementia include:

  • Forgetfulness
  • Confusion
  • Finding it hard to follow conversations
  • Trouble with controlling your mood or behaviour

Most older people do not get dementia but those who are affected are usually over the age of 65. There are things you can do to help reduce your chances of getting dementia.

These include:

  • Eating a healthy diet and maintaining a healthy weight
  • Be physically active
  • Limit alcohol intake
  • Give up smoking
  • Stay mentally and socially active
  • Managing your general health
Would you like us to send you further information about dementia?

Alcohol Screening

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? *

Physical Activity Review (GPPAQ)

Level of physical activity involved at work: *
Number of hours in the last week spent doing physical activity? *
Number of hours in the last week spent cycling? *
Number of hours in the last week spent walking? *
Number of hours in the last week spent in housework / childcare? *
Number of hours in the last week spent gardening or doing DIY? *
How would you describe your walking pace? *
Would you like the Nurse to contact you for a follow up consultation?
How would you prefer this follow up consultation?