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

5 Yearly Health Check

Blood Pressure

Smoking Status

Alcohol Status

Exercise