NHS Health Check

Gender: *

Male

Female

Indeterminate

Ethnicity

Please specify:

First Language: *

Do you speak English? *

Yes

No

Do you read English? *

Yes

No

Body Mass Index

Height (in Meters): *

e.g 1.75

Weight (in Kilograms): *

e.g 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over.

Smoking Status

Smoking status: *

Smoker

Never smoked

Ex smoker

How many do you smoke per day? *

Less than 10

10-12

More than 20

Getting expert support and advice from your local stop smoking service will mean you are four times more likely to succeed at quitting smoking than going at it alone.

Please visit Healthy Surrey: Stop Smoking to start your journey.

How many did you smoke per day? *

Less than 10

10-12

More than 20

When did you give up smoking? *

Your Blood Pressure

Please provide a blood pressure reading if you have access to a BP monitoring machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Systolic "Higher"

Diastolic "Lower"

Heart Rate

Is your pulse regular?

Yes

No

Alcohol

This is 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 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? *

Physical Activity: GPPAQ

1. Please tell us the type and amount of physical activity involved in your work: *

I am not in employment (e.g. retired, retired for health reasons, unemployed, full-time carer etc.)

I spend most of my time at work sitting (such as in an office)

I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.)

My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)

My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

2. During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc.? *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Cycling, including cycling to work and during leisure time? *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Walking, including walking to work, shopping, for pleasure etc.? *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Housework or childcare? *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Gardening or DIY? *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

3. How would you describe your usual walking pace? *

Slow pace (ie. less than 3mph)

Steady average pace

Brisk pace

Fast pace (ie. over 4mph)

Family History

Have any of your immediate relatives had any of the following diagnosed under the age of 60:

Heart Attack

Angina

Diabetes

Stroke

Tell us whether you accept cookies

NHS Health Check

Ethnicity

Body Mass Index

Smoking Status

Your Blood Pressure

Alcohol

This is one unit of alcohol:

And each one of these, is more than one unit:

Physical Activity: GPPAQ

Family History

COVID-19 Vaccinations