Health Check "*" indicates required fields Name* DrMissMrMrsMsProf.Rev. Prefix First Last Date of Birth* Day Month Year Email* Enter Email Confirm Email Contact Number*Height* Weight* Waist Circumference* What is your ethnic group?* White Black Asian Mixed Other Please Specify:* British Caribbean Indian Irish African Pakistani Other Blood PressureSystolic (top number)* If this number is over 160. Please call the practice or 111Diastolic (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 StatusWhat is your smoking status?*Please SelectSmokerEx-SmokerNever smokedWhen did you stop smoking?* Day Month Year How many cigarettes do you smoke a day?* Alcohol StatusOn average how many alcohol units do you have per week?* 1 unit =small glass of wine, Pub measure spirits or half a pint beerExerciseAverage hours of exercise per week?* Additional Information Optional