NHS Health Check Form

 

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Personal Details
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Ethnicity
 
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General Health Questions
 
  
 
  
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

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. 

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

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

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
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.

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.

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