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NHS health check

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.

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?

Alcohol Screening

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? *

Additional alcohol consumption questions

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from 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? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *
Confirmation *

Please ask at reception for more information about giving up smoking.