Wellbeing Health Check Questionnaire

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Personal Details

Are you happy for us to add/update your mobile to your medical records?: *

Are you happy for us to contact you via SMS text messages?: *

Are you happy for us to add your email to your medical records?:

Are you happy for us to contact you via emails?:

Do you require an interpreter when you see the doctor/nurse?:

Observations

if you do not know, please put 0 in the field above

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

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.

Exercise

Support

Would you like support to lose weight, if applicable?:

Would you like support with diet?:

Would you like support with exercise?:

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)

Exercise on referral - Healthwise with subsidised discount, with regular asessments to support you over a 6 - 12 week period (Correct as of; 12/07/2021 £25 direct debit per month or £4 pay and play per activity for 24 hours during your intervention, access to gym, swimming and classes)
LEEP - Pulmonary Rehabiltation - for those with COPD
One to one dietitian - local service
Weight watchers or Slimming world - free on the NHS for 12 weeks
Diabetes Prevention Programme
NHS Digital Weight Management Online Programme - For patients with Diabetes and / or Hypertension (High BP)
DESMOND - Type 2 Diabetes Educational Programme
DAFNE - Type 1 Diabetes Educational Programme
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

Please check the boxes, that you would be interested in, if you are suitable, eligible and ready to make changes?: *

*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.

If applicable, would you like to have a blood test?: *

Where do I get a blood test?

First please wait to receive a text message from us to let you know that a blood test is required.
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.
If you are due, we will send you a text.
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 a KLINIK form. 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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Wellbeing Health Check Questionnaire

Would you like support to quit?

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 ()

If you are eligible and meet criteria, there are places we can refer you to for support

Where do I get a blood test?

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