Health Questionnaire

Please state any health problems, illnesses or injuries that you are experiencing now, or have had in the past (including childhood illnesses):

What prescribed medicines (or others that you may have bought) are you currently taking, if any?

Is there any history of any of the following in your immediate family (include parents, siblings and children):

How do you view your health?

Please state:

What do you hope to achieve by attending a "Wellness Health Check"?

Smoking Habits

Do you smoke?

Have you ever smoked?

Drinking habits

In an average week, how many units per week do you drink?

Remember 1 unit =
1 small (125ml) glass of wine
Half a pint of beer, lager or cider (4%)
1 small measure (25 ml) of spirits e.g. gin, rum, vodka or whisky

Physical Activity

How many times a week do you exercise?

How long for? (number of hours)

What form does this take? E.g walking/gym/swim

Diet

Tell us what you think about the diet you have:

Consent

In order to give you the best possible care we request that you agree and sign the following;
I give consent to investigation, advice and sharing of information with relevant services
Agree:

Disclaimer

This health check is not a full medical examination. Any health concerns arising following this check should be addressed and follow up care sought e.g. GP or A&E if necessary. If any particular concerns are identified during the course of this health check, you will be referred on as appropriate e.g. to your GP.
Disclaimer: