NHS Health Check (Pre-assessment questionnaire)

If you have been asked to submit a NHS Health Check (Pre-assessment questionnaire), please complete this form.

The information collected in this questionnaire will be used for evaluation, signposting and service improvement and will not be shared with non NHS agencies without your permission.

NHS Health Check (Pre-assessment questionnaire)

NHS Health Check (Pre-assessment questionnaire)

Section

On an average day how many portions of fruit and vegetables do you eat? (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) *
Do you smoke? *
On an average week, how many days would you usually do at least 30 minutes of moderate intensity physical activity? (Moderate intensity physical activity means working hard enough to raise your heart rate and make you feel warm, yet still being able to carry on a conversation.) *
How often do you have a drink that contains alcohol? *
How many drinks do you have that contain at least one unit of alcohol on a typical day when you are drinking? (One unit is about equal to half a pint of ordinary strength beer, lager or cider, a standard pub measure of spirits or small glass of ordinary strength wine)
How often do you have 6 or more drinks that contain at least 1 unit of alcohol on one occasion? (One unit is about equal to half a pint of ordinary strength beer, lager or cider, a standard pub measure of spirits or small glass of ordinary strength wine)
Has an immediate family member suffered from either a heart attack or angina under 60 years of age? (Your parents, brother or sister) *
Has an immediate family member been diagnosed with diabetes? *
What ethnic group are you from? It is important for us to know this as risks for some diseases changes depending on your ethnicity. *
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