Patient Health Check Questionnnaire

Patient Health Check Questionnaire


If you are unable to check your own BP and weight or need further health education advice, please make an appointment with one of our HCA’s.

Blood Pressure



Are you a carer?

Carer packs are available for collection from reception. Please visit for usefuol information about being a carer.


Do you smoke?
Would you like any advice on stopping smoking?

We can offer referrals to our local smoking cessation service, please speak to our receptionist or one of the HCA’s.

Visit the Smokefree website for information about smoking cessation.


To keep health risks from alcohol at a low level it is safest not to drink more than 14 units of alcohol per week on a regular basis. This is best spread over 3 or more days of the week.

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? *


Do you have any concerns regarding your memory?


Would you describe your diet as healthy?

Further information regarding healthy eating and weight management can be found at:

Physical Activity

How would you describe your current level of physical activity:

Family History

Please specify if any of your immediate family have any of the following:

Females Only

Further information about all methods of contraception can be found at

Please request an appointment with one of our Women’s Health nurses if wishing to discuss further.

Do you use any of these long-acting methods of contraception?