NHS Health Check

If you have been advised by the practice to complete an NHS Heath Check please use this form.

NHS Health Check

NHS Health Check

Gender: *


Please specify the ethnic group you consider you belong to: *
Do you speak English? *
Do you read English? *

Body Mass Index

e.g 1.75
e.g 60.6
Please note: BMI calculator is only for patients aged 18 and over.

Smoking Status

Smoking status: *
How many do you smoke per day? *

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? *

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.

Please use date format: DD/MM/YYYY
Is your pulse regular?


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? *

Physical Activity: GPPAQ

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

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.? *
Cycling, including cycling to work and during leisure time? *
Walking, including walking to work, shopping, for pleasure etc.? *
Housework or childcare? *
Gardening or DIY? *
3. How would you describe your usual walking pace? *

Family History

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