NHS Health Check

During the COVID-19 pandemic we have had to change the way that we carry out our NHS health checks. As part of our new way of working, if you have been invited for an NHS Health Check, please complete the questionnaire below. Once you have completed the questionnaire, please ring our Reception to arrange a face-face appointment where our staff will take further measurements and some blood tests.

You may not be eligible for an NHS health check if you have a number of different health conditions. Please also note that patients are only offered one NHS health check every 5 years.

Please only complete this form if you have been invited for a health check. The form has been divided into sections for ease of use, due to the amount of information that we need to collect.

Your Details

First Name *

Last Name *

Date of Birth *

Address *

Email Address

Home Telephone Number *

Mobile Number

What is your ethnicity? *

Please indicate if you are a military veteran *

Your Height and Weight

What is your height in cm? *

What is your weight in kg? *

What is your waist circumference? *

To measure your waist:

1. Find the bottom of your ribs and the top of your hips
2. Wrap a tape measure around your waist, midway between these points
3. Make sure it’s pulled tight, but isn’t digging into your skin.
4. Breathe out naturally before taking the measurement

Your Blood Pressure

Please submit an average of 10 blood pressure readings over 5 consecutive days *

If you don’t have a blood pressure monitor please write a note in the box

On each day, monitor your blood pressure on two occasions: in the morning (between 6am and 12noon) and again in the evening (between 6pm and midnight). If you are prescribed blood pressure medication then take this usual, unless told otherwise by a doctor.

On each occasion take a minimum of two readings and record the lowest, leaving at least a minute between each. If the first two readings are very different, take 2 or 3 further readings.

Take your blood pressure before eating, as digesting food can lower your blood pressure. If you must eat first, wait 30 minutes after eating before taking a measurement. It is also important that you haven’t had a cigarette within 30 minutes of taking your blood pressure as smoking can increase your readings.

Your Diet

Tell us about your diet *

Please add any further information you feel is relevant

Your Smoking History

Please tell us about your smoking status *

Your Alcohol Data

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

Your Exercise

How much activity do you do at work? *

How many hours in the last week did you spend doing physical exercise? *

How many hours in the last week did you spend cycling? *

How many hours in the last week did you spend walking? *

What is your normal walking speed? *

How many hours in the last week did you spend on housework or childcare? *

How many hours in the last week did you spend gardening or doing DIY? *

Your Mental Health

In the last month have you felt little pleasure or interest in doing things? *

In the past month have you often felt down, depressed or hopeless? *

Do you have any concerns about your memory? *

Your Family History

Please indicate if anyone in your family has angina or has suffered from a heart attack or stroke *

For family members that have any of the above conditions please indicate their relationship to you and the approximate age that they were, when they were diagnosed.

If no family members are affected then please add this to the box

Are there any other conditions that run in your family?

I confirm that I am a registered patient at Southam Surgery*

Fields marked with an asterisk (*) are mandatory

FAQs

What is an NHS Health Check?

The NHS Health Check is a free check-up of your overall health and is offered to adults in England aged between 40 to 74 years, every 5 years.

It’s designed to help prevent, as well as spot the early warning signs of stroke, kidney disease, heart disease, type 2 diabetes or dementia.

If patients are identified as having a risk for any of the above conditions, advice can be given to try and help reduce this risk.

Our NHS Health Check Questionnaire

You may not be eligible for an NHS health check if you have a number of different health conditions. Please also note that patients are only offered one NHS health check every 5 years.

Height and Weight

To measure your waist:

Blood Pressure

On each occasion take a minimum of two readings and record the lowest, leaving at least a minute between each. If the first two readings are very different, take 2 or 3 further readings.

NHS Health Check

Your Details

Your Height and Weight

Your Blood Pressure

Your Diet

Your Smoking History

Your Alcohol Data

Your Exercise

Your Mental Health

Your Family History

Patient Info

Policies

About Us

Locations

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CQC Rating

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