NHS Health Check Form

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Personal Details

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Ethnicity

Please specify the ethnic group you consider you belong to: *

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General Health Questions

Which units of Height are you using:

Which units of Weight are you using:

Your systolic blood pressure is the top number on your reading

Your diastolic blood pressure is the bottom number on your reading

Your pulse rate is the number of times your heart beats per minute

Smoking Review

Do you currently smoke?: *

How many cigarettes do you smoke in a day?: *

Would you like to give up smoking?: *

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

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Physical Activity Questions

Please tell us the type and amount of physical activity involved in your work.

Please choose the closest to your present work from the following five possibilities:: *

During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc.: *

Cycling, including cycling to work and during leisure time: *

Walking, including walking to work, shopping, for pleasure etc.: *

Housework/Childcare: *

Gardening/DIY: *

How would you describe your usual walking pace?: *

Your PAI Score is "Active"

Your PAI Score is "Moderately Active"

Your PAI Score is "Moderately Inactive"

Your PAI Score is "Inactive"

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Your Personal Alcohol Consumption

1 unit of alcohol is 218ml cider standard 4.5% ABV, 76ml Wine Standard 13% ABV, 25ml Whisky Standard 40% ABV, 250ml Beer Standard 4% ABV or 250ml Alcopop Standard 4% ABV

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 do you have 8 or more units on one occasion?: *

Audit Score Result 0 - 7 (Lower Risk)

Low Risk - you have a score of ()

Your answers suggest you are at a lower risk of being dependent on alcohol.

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Your Personal Alcohol Consumption - Part 2

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?: *

Audit Score Result 8 - 15 (Increasing Risk)

( Increasing Risk ) - you have a score of ()

Your answers suggest you are at an increasing risk of being dependent on alcohol.

Your drinking is dangerous to your health, increasing your risk of serious health problems including seven types of cancer, liver and heart disease, and high blood pressure. Unless you cut down you are at risk of damaging your health.

Audit Score Result 16 - 19 (Higher Risk)

(( Higher Risk )) - you have a score of ()

Your answers suggest you are at Higher Risk of being dependent on alcohol.

Your drinking is dangerous to your health. You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week. Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.

Audit Score Result 20+ (Possible Dependence)

(( Possible Dependence )) - you have a score of ()

Your answers suggest you are at High Risk of being dependent on alcohol.

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NHS Health Check Form

Low Risk - you have a score of ()

( Increasing Risk ) - you have a score of ()

(( Higher Risk )) - you have a score of ()

(( Possible Dependence )) - you have a score of ()

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