General Annual Patient Check

We aim to keep our patient records up to date by asking about some basic health matters.

We would appreciate your time in completing and submitting this questionnaire to us.

General Annual Patient Check

General Annual Patient Check

Section

Weight, Diet and Physical Activity

Diet type:
Diet quality:
Exercise:

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 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? *

Smoking

Smoking status:
Please select all that apply:

If you would like help to stop smoking, please contact the team for free at Smokefree Norfolk.

You can visit their website at www.smokefreenorfolk.nhs.uk or, alternatively, you can call their freephone line on 0800 0854113.

Please select all that apply:

Additional Information

Do you have any of the following medical conditions:
Ethnic group: