Digital NHS Health Check - Hightown Surgery

We are currently piloting a new ‘Digital NHS Health Check’.

By making health checks more convenient and accessible, we can hopefully provide more of our eligible patients with this check and in turn identify more people who may be at risk and therefore take measures to reduce their long-term risks. Please allow 20mins for the questionnaire and answer all the questions.

Your results provide a deeper understanding of your health, so that you can take the steps necessary to take control of your health and wellbeing.

Health Check form

About you

Name

First Last

Date of Birth

Ethnicity

Are you a carer?

Do you care for loved one? This is NOT asking if you are employed as a carer.

Family history

Family history of diabetes

Family member

Family history of cardiovascular disease (CVD)

Family member

Smoking status

How many times per day?

Alcohol consumption

Do you drink alcohol?

How often did you have a drink containing alcohol in the last year?

How many units of alcohol do you drink on a typical day when drinking?

How often did you have 6+ units (female) or 8+ units (male) on a single occasion in the past year?

How often in the last year have you found that you were not able to stop drinking once starting?

How often during the last year have you failed to do what was normally expected of you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Physical activity

Activity at work

Exercise

Amount in the last week

Cycling

Amount in the last week

Walking

Amount in the last week

House work / Child care

Amount in the last week

Gardening / DIY

Amount in the last week

Walking pace

What is your usual level of walking pace?

Physical stats

Reading your pulse – One of the easiest places to feel your pulse is on your wrist, just below your thumb • With your palm facing up, place the index and middle finger of the other hand firmly on the wrist and keep pressure on your wrist with your fingers to feel your pulse • Set a timer for 60 seconds • Count the number of beats and observe the rhythm • A normal rhythm has an even gap between beats (ticks like a clock)

Pulse rate

Please enter a number from 30 to 250.

number of beats per minute when resting

Pulse rhythm

Blood pressure reading

eg 135/78

Waist circumference

measured in centimetres

Standing height

Measured in centimetres

Body weight

measured in kg