NHS Health Check Questionnaire

If you have been advised by the surgery to submit an NHS health check questionnaire, please use this form.

Please complete what you can. The clinician may go over some of the following question areas again during your health check appointment. Any answers from the questions below that you can complete will help them. If you are unsure of any sections or have answers that do not have an option, don’t worry as the clinician will be able to go over these during your appointment.

NHS Health Check

NHS Health Check

NHS Health Checks are free for anyone aged between 40 and 74 years of age and does not already have a pre-existing condition. Patients can have a check once every 5 years.

It can tell you whether you're at higher risk of getting certain health problems, such as heart disease, diabetes, kidney disease, stroke and dementia.

Section

Blood Pressure

If you have a blood pressure monitor at home, please provide a couple of readings below or have them to hand when you speak to the clinician.

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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:
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 call their freephone line on 0800 0854113.

Weight, Diet and Physical Activity

Diet type:
Diet quality:
Exercise:

Additional Information

Family history (if known):
Ethnic group:

Please note, your ethnicity will make a difference on some testing results.