You are here: Online Services> Health Questionnaire  Bookmark this page

Health Questionnaire
 

1. Please fill in all the grey boxes.
2. Use the TAB button on your keyboard, or use your mouse to the next box. Please do NOT hit Enter on your keyboard. If you do this, you will be told you have not filled in the form correctly and asked to do it again.
3. You must accept the Terms & Conditions of this service by ticking the checkbox at the bottom of the form. You will not be able to use this form without accepting the Terms & Conditions of Service

 

Your Details

First Name*

Surname*

Phone Number

E-mail Address

 

 


 

Basics

Your Date of Birth                     Weight                                        Height
                             

Have you had your Blood Pressure checked in the last 10 years?

Have you had a Tetanus Jab in the last 10 years?

What is your Occupation?

Do you take any form of exercise?

 

Lifestyle

Do you Smoke?

If you smoke, how many do you smoke per day?
   or ounces:

If you smoke, what do you smoke?

Have you previously stopped smoking, if so when?

If you are a smoker and would like help giving up smoking, we have a smoking cessation clinic set up at the practice, would you like more information on this?

 

How many units of alcohol do you drink on an average week?

How often do you have 8 units(men) / 6 units(women) or more drinks on one occasion?

How often in the last year have you not been able to remember what happened when drinking the night before?

How often in the last year have you failed to do what was expected of you because of drinking?

Has a relative / friend / doctor / health worker been concerned about your drinking or advised you to cut down?

 

History

Has anyone in your family under the age of 60 had:

 - A Heart Attack / Heart Disease
 - Stroke
 - Blood Clot
 - Cancer

Do you have any significant past medical history / family history that you think may be valuable to us?

Do you have any further comments that you think may be valuable?

 

Other

Do you have any known allergies?

Do you have any known medicine allergies?

What is your Ethnic Group?
         Other:

Ethnic Information Refused

 

Terms & Conditions

I accept the terms & conditions of Service*

 

Copyright © Grosvenor Road Surgery 2005 - 2011