Important: Invitation only

This form should only be completed if you have received an invitation (letter or text) to book this review.

NHS Health Check
Have you received an invitation (letter or text) to book this review? *

You must have received an invitation to book a NHS Health Check in order to submit this form.

Patient Details

Please use this date format: DD/MM/YYYY.

Exercise

1. Physical activity at work

Please tell us the type and amount of physical activity involved in your work, tick the box that is most relevant to you:

2. Physical Exercise

During the last week, how many hours approximately did you spend on each of the following activites? Please state amount in each box:

Diet

How would you say you diet is from Good, Average, or Poor?

Smoking

Do you currently smoke tobacco?
Do you currently smoke an e-cigeratte/vape?

Yes

How many cigarettes do you smoke in a day?
Would you like to give up smoking?
Would you like support to stop smoking?

No

Have you smoked in the past?
How many cigarettes did you smoke in a day?

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? *