5 Yearly Health Check

Every 5 years we ask patients to complete a health information update. This consists of a short lifestyle questionnaire and height, weight and blood pressure measurements. This enables us to keep your medical records up to date.

Name

Prefix First Last
Date of Birth

Day
Month
Year
Email

Enter Email Confirm Email
Contact Number
Height
Weight
Waist Circumference
Blood Pressure
Systolic (top number)

If this number is over 160. Please call the practice or 111
Diastolic (bottom number)

If this number is 100 or over. Please call the practice or 111.
Pulse

If your pulse is below 45 or above 100. Please call the practice or 111
Smoking Status
What is your smoking status?
When did you stop smoking?

Day
Month
Year
How many cigarettes do you smoke a day?
Alcohol Status
On average how many alcohol units do you have per week?

1 unit =small glass of wine, Pub measure spirits or half a pint beer
Exercise
Average hours of exercise per week?
Additional Information Optional

5 Yearly Health Check

Blood Pressure

Smoking Status

Alcohol Status

Exercise