NHS Health Check Questionnaire

If you have been advised by the surgery to submit an NHS health check questionnaire, please use this form. Then please phone reception and book an appointment for an NHS healthcheck.

Please complete what you can. The clinician may go over some of the following question areas again during your healthcheck appointment. Any answers from the questions below that you can complete will help them. If you are unsure of any sections or have answers that do not have an option, don’t worry as the clinician will be able to go over these during your appointment.

NHS Health Check Questionnaire

NHS Health Check

NHS Health Checks are free for anyone aged between 40 and 74 years of age that do not already have a pre-existing condition. Patients can have a check once every 5 years.

The healthcheck can tell you whether you’re at higher risk of getting certain health problems, such as heart disease, diabetes, kidney disease, stroke and dementia.

Please use format day/month/year e.g. 12/05/1979

Blood Pressure

If you have a blood pressure monitor at home, please provide a couple of readings below or have them to hand when you speak to the clinician.

First reading

Second reading

Do you drink alcohol?

Alcohol Consumption

Units of Alcohol

chart showing alcohol units

Automatically calculated

Smoking

Smoking Status
Please select all that apply

Everybody knows that smoking is harmful to your health. Find out more about the benefits of giving up smoking and the support available.

Contact Smokefree Norfolk by calling 0800 0854113 or visit www.smokefreenorfolk.nhs.uk

Please select all that apply:

Weight, Diet and Physical Activity

Diet type:
Diet quality:
Exercise:

Additional Information

Family history (if known):
Ethnic group:

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.