Having up to date health details about our patients is vital
in providing the best healthcare possible.
If you have received a health questionnaire in the post, or
have been given one in the surgery, you can fill this out
here on the website and send it to us directly to save you
filling it out on paper and sending it back to us.
If you have not received a health questionnaire from us,
please do take the time to fill this in, it will help us
immensely, thank you.
Please fill in all
the boxes.
Use the TAB button on your keyboard, or your
mouse to navigate between boxes. Please do not hit
enter on your keyboard.
You must accept the Terms & Conditions of this
service by ticking the checkbox at the bottom of the
form. You will not be able to use this form without
accepting the Terms & Conditions of Service.
Basics
Your Date of Birth Weight Height
Have you had your Blood
Pressure checked in the last 10 years?
Have you had a Tetanus Jab
in the last 10 years?
What is your Occupation?
Do you take any form of
exercise?
Lifestyle
Do you Smoke?
If you smoke, how many do
you smoke per day?
or ounces:
If you smoke, what do you
smoke?
Have you previously
stopped smoking, if so when?
If you are a smoker and
would like help giving up smoking, we have a smoking
cessation clinic set up at the practice, would you
like more information on this?
How many units of alcohol
do you drink on an average week?
How often do you have 8
(men) / 6 (women) or more drinks on one occasion?
How often in the last year
have you not been able to remember what happened when
drinking the night before?
How often in the last year
have you failed to do what was expected of you because
of drinking?
Has a relative / friend /
doctor / health worker been concerned about your
drinking or advised you to cut down?
History
Has anyone in
your family under the age of 60 had:
- A
Heart Attack / Heart Disease
- Stroke
- Blood Clot
- Cancer
Do you have any
significant past
medical history / family history that you think may be valuable to us?
Do you have any further
comments that you think may be valuable?
