Annual health review

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

I am not in employment (retired, retired for health reasons, unemployed, full-time carer etc)

I spend most of my time at work sitting (office work etc)

I spend most of my time at working standing/walking, it does not include intense physical effort (Shop assistant, hairdresser, security guard etc)

My work involves definite physical effort including handling of heavy objects/use of tools (plumber, electrician, cleaner, nurse)

My work involves vigorous physical activity (scaffolder, refuse collector, personal trainer)

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

Physical exercise (swimming, jogging, aerobics, football, tennis, gym workout etc):

Cycling, including cycling to work and during leisure time:

Walking, including walking to work, shopping and for pleasure:

Housework/Childcare:

Gardening/DIY:

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

Good Diet (3 meals a day, including 5 servings of fruits and vegatables, plenty of water)

Average

Poor (mainly consistening of fast foods, no fruit or vegetables, and no water)

Do you currently smoke tobacco?

Yes

No

Have you ever smoked?

Yes

No

Do you currently smoke an e-cigeratte/vape?

Yes

No

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? *

Please state below should you have any queries/would like any support with any of the above:

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

Yes

No

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