Wellbeing Questionnaire Wellbeing Questionnaire Health Check Questionnaire "*" indicates required fields Personal DetailsName* First Last Date of Birth* MM slash DD slash YYYY Phone Number*Email Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Are you happy for us to add/update your mobile to your medical records?* Yes No Are you happy for us to contact you vis SMS text message?* Yes No Are you happy for us to add your email to your medical records? Yes Optional No Optional Are you happy for us to contact you via email? Yes Optional No Optional Ethnicity*Select on optionWhite BritishWhite IrishOther WhiteBlack CaribbeanBlack AfricanOther BlackBlack Caribbean and WhiteBlack African and WhiteOther MixedIndianPakistaniBangladeshiOther AsianOther ethnic groupDo not wish to sayDo you require an interpreter when you see the doctor nurse? Yes Optional No Optional ObservationsHeight* If you do not know, please put 0 in the field aboveWeight* If you do not know, please put 0 in the field above Blood Pressure Reading (if known) Optional Heart Rate (BMP) Optional Do not worry if you do not know thisIf you check your own blood pressure and it’s higher than (TOP number) 135 and / or (BOTTOM number) 85; please call 020 3474 6730 and arrange a blood pressure review with a nurse as soon as possible. Smoking StatusSmoking Status*Select one optionSmokerEx SmokerNever SmokedCurrent Smoker, how many a day do you smoke?* Ex Smoker, when did you last smoke?* Your Personal Alcohol ConsumptionHow often do you have a drink containing alcohol?*Select one optionNeverMonthly or less2-4 times a month2-3 times a week4 or more times per weekHow many units of alcohol do you drink on a typical day when you are drinking?*Select one option1-23-45-67-910+How often do you have 8 or more units on one occasion?*Select one optionNeverLess than monthlyMonthlyWeeklyDaily or almostExercisePlease tell us the type and amount of physical activity involved in your work?*Select one optionNot in employmentSpends most of time at work sittingSpends most of time at work standing or walkingWork involves definite physical effortWork involves vigorous physical activityDuring the last week, how many hours did you spend doing physical exercise?*Select one optionNoneSome but less than 1 hour1 hour but less than 3 hours3 hours or moreDuring the last week, how many hours did you spend cycling? OptionalSelect one optionNoneSome but less than 1 hour1 hour but less than 3 hours3 hours or moreDuring the last week, how many hours did you spend doing house work/child care? OptionalSelect one optionNoneSome but less than 1 hour1 hour but less than 3 hours3 hours or moreDuring the last week, how many hours did you spend gardening/ DIY? OptionalSelect one optionNoneSome but less than 1 hour1 hour but less than 3 hours3 hours or moreDuring the last week, how many hours did you spend walking? OptionalSelect one optionNoneSome but less than 1 hour1 hour but less than 3 hours3 hours or moreWhat is your usual level of walking pace?*Select one optionSlowSteadyBriskFastSupportWould you like support to lose weight, if applicable?* Yes No Would you like support with diet?* Yes No Would you like support with exercise?* Yes No Referral OpportunitiesIf you are eligible and meet criteria, there are places we can refer you to for support. Referral Opportunities that may be available to you: (click on each one below to find out more about the opportunity/opens in a new window) • Exercise on Referral • Family Health Support • Smoking Cessation Support • Alcohol Advice • NHS Digital Weight Management Online Programme – For patients with Diabetes and/or Hypertension (High BP) • Specialist dietitian – Tier 3 weight management (for those with BMI > 40 or BMI 35 with Type 2 diabetes) • Bariatric surgery – (Note: you may have to complete other referral schemes before a referral can be made for this; please speak to a nurse) • One to one dietitian • Weight watchers or slimming world – free on the NHS for 12 weeksPlease check the boxes, that you would be interested in, if you are suitable, eligible and ready to make changes?* Exercise on Referral Family Health Support Smoking Cessation Support Alcohol Advice NHS Digital Weight Management Online Programme Specialist dietitian – Tier 3 weight management Bariatric surgery One to one dietitian *note: you may express that you would like to attend many of the above, but if you do not meet criteria or not eligible, we cannot refer you. Also note; we do need to have an up-to-date blood test, blood pressure check, heart rate, height and weight recorded to refer to most of these. If any of these are required, we will contact you to come in and see a nurse.Blood TestIf applicable, we would like to offer you to have a blood test. We would like to check for: HbA1c – which checks your blood sugars for diabetes Lipids (fasting) – which checks your cholesterol levels U&Es – which checks your kidney functions LFTs – which checks your liver is working properly. You may have had a blood test in the last 6 months, for all or some of these, but if not, we’d like you to have these done as soon as possible. *Note: we may want to test you for other things, for example, if you are overdue for an existing medical condition, or due to your age. We will contact you if we want you to do extra tests.If applicable, would you like to have a blood test? Yes Optional No Optional End of Questions – Please submit form belowIt may take up to 12 weeks to review your health questionnaire. We will contact you if you have expressed interest in a blood test or an onward referral, and / or if we need to obtain more information from you. Privacy Consent This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.Untitled I consent to the practice collecting and storing my data from this form. Optional
