Wellbeing Health Check Questionnaire

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Personal Details
Observations
if you do not know, please put 0 in the field above
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Do not worry if you do not know, as we will invite you in to take this

If 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.

But please continue to complete and submit this form.

Smoking Status
Please select one

Would you like support to quit?

Visit SMOKE FREE LEWISHAM to get further support, or call 0800 0820 388 or email quit@smokefreelewisham.co.uk to book your first appointment

They offer free, friendly, practical support and advice on medications to support you while you stop smoking.

The support is free and all medications are available on prescription.

Your Personal Alcohol Consumption

1 unit of alcohol

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.

Exercise
 
Support
Referral Opportunities

If 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)

*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 Test

If 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 exisiting medical condition, or due to your age. We will contact you if we want you to do extra tests.

Where do I get a blood test?

  1. First please wait to receive a text message from us to let you know that a blood test is required.
  2. If you do not hear from us regarding a blood test, and you requested one, it means you are up-to-date and not due one now. In 6 months time, please request a blood test from the nurse or doctor.
  3. If you are due, we will send you a text.
  4. You can collect the blood test form from reception, you would then need to book a blood test appointment by calling the centralised number on 020 8333 3217 (Mon-Fri 8am-4pm) or visit this online booking form.

These blood tests are essential for us to make sure you are healthy and helps us to refer you to any services you have requested to be referred to. 

End of Questions - Please submit form below

It 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.

If you have an urgent query, or want advice sooner, please contact the practice on 020 3474 6730, complete an eConsult, or download and use the ASKFIRST app. Remember you can call 111 for urgent problems, or 999 in case of life threatening situation.

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.

 
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