NHS Health Check (Pre-assessment Questionnaire)

Your doctor has invited you for a NHS cardiovascular disease health check because you do not have heart disease, diabetes, stroke, high blood pressure or chronic kidney disease. The purpose of this questionnaire is to help us find out your current risk of developing these diseases so it is important that you answer each question as accurately as you can.

If you have been advised by the surgery to submit a NHS Health Check Questionnaire please use this form.

What is an NHS Health Check?

NHS Health Check (Pre-assessment Questionnaire)

If you are human, leave this field blank.

Patient Details

First Name: *

Surname: *

Date of Birth: *

Please use date format DD/MM/YYYY

Telephone Number:

Mobile Number:

Email Address: *

All responses will be sent this email address.

Ethnicity

It is important for us to know this as risks for some diseases change depending on your ethnicity.

What ethnic group are you from? *

White British

White Irish

Other White Background

White and Black Caribbean

White and Black African

White and Asian

Other Mixed Background

Chinese

Indian

Pakistani

Bangladeshi

Other Asian Background

Caribbean (Black/Black British)

African (Black/Black British)

Other Black Background

Other

Please specify: *

Your Diet

On an average day, how many portions of fruit and vegetables do you eat? *

Under 3

3 to 4

5 or more

A portion is roughly a handful e.g. a medium apple or pear, 7 strawberries or cherry tomatoes, 2 satsumas, vegetables (not potatoes) or a glass of juice

Smoking

Smoking Status: *

Current Smoker

Ex-Smoker

Never Smoked

What year did you quit? *

How many do you smoker per day? *

1 to 9

10 to 19

20 to 39

40 or more

Exercise

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).

During the last week, how many hours did you spend on each of the following activities (please answer whether you are in employment or not):

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout, etc. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *

0

Less than 1 hour

Between 1 and 3 hours

3 or more hours

Cycling (including cycling to work) and during leisure time. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *

0

Less than 1 hour

Between 1 and 3 hours

3 or more hours

Walking (including walking to work), shopping, etc. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *

0

Less than 1 hour

Between 1 and 3 hours

3 or more hours

Housework or childcare. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *

0

Less than 1 hour

Between 1 and 3 hours

3 or more hours

Gardening or DIY. (some but less than an hour, 1 hour but less than 3 hours, 3 hours or more, none). *

0

Less than 1 hour

Between 1 and 3 hours

3 or more hours

How would you describe your usual walking pace? *

Slow

Steady

Brisk

Fast

Alcohol

This is one unit of alcohol:

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

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

View your score