Health Check Assessment
Disclaimer
Section 1
Section 2
Section 3
Section 4
Workbook submitted. Thank you!
Introduction
Is this your first health screen:
Yes
No
If not, when and where was your last screen
Demographic
GP Name
GP Address
GP Phone Number
Current Symptoms
Do you have any medical concerns at present?:
Yes
No
If yes please give details
Explain your reason for attending
Medications
Are you taking any medications?:
Yes
No
If so, can you list them
Name:
Dose:
Frequency:
Allergies
Do you have any medical allergies?:
Yes
No
If so, can you list them
Name of medication:
Reaction:
Do you have any other significant allergies (latex, plasters, shellfish, nuts, etc.):
Yes
No
If so, can you list them
Name of medication:
Reaction:
Medical & Surgical History
Do you currently suffer from any illness e.g high BP, cholesterol, diabetes:
Yes
No
Details
Have you had an accident or undergone surgery recently?
Yes
No
Details
Are you participating in the following national programmes, if yes, please give details of last screening date?
National Bowel Screening (60-69 years)
Yes
No
Women only
Breast Check (50-69years)
Yes
No
Cervical Check (25-65 years)
Yes
No
When was your last cervical smear?
Have you ever had an abnormal smear?
Yes
No
If yes, please give details
Obstetric History
Number of pregnancies
Outcome (babies, miscarriages, terminations)
Any complications during pregnancy?
Breast History
Have you ever had a mammogram?
Yes
No
If yes, what result
Have you ever had a breast problem in the past?
Yes
No
If yes, please give details
Family History
Father
Age
State of health
If deceased, age at time of death
Cause of death
Mother
Age
State of health
If deceased, age at time of death
Cause of Death
Brothers
Age
State of health
If deceased, age at time of death
Cause of death
Add brother
Sisters
Age
State of health
If deceased, age at time of death
Cause of death
Add Sister
Is there any history of the following in your family
Epilepsy:
Yes
No
Diabetes:
Yes
No
Alcoholism:
Yes
No
Heart/Blood vessel disease:
Yes
No
Stroke:
Yes
No
Gout:
Yes
No
High blood pressure:
Yes
No
Glaucoma:
Yes
No
Cancer:
Yes
No
Haemochromatosis:
Yes
No
Thyroid disease:
Yes
No
Cancer of Ovaries:
Yes
No
If yes, please give details
Cancer of Breast:
Yes
No
If yes, please give details
Cancer of Uterus:
Yes
No
If yes, please give details
Spouse/Partner State of Health
Children State of Health
Family History
Social History
Martial Status:
Single
Married
Cohabiting
Separated
Widowed
Divorced
Years married
Number of:
Sons
Ages
Daughters
Ages
Occupation
Accountancy & Taxation
Accountancy, Finance & Insurance
Advertising, Marketing & Public Relations
Animals & Veterinary Science
Art, Craft & Design
Banking & Financial Services
Biological, Chemical & Pharmaceutical Science
Biomedical Technologies & Medtech
Business Management & Human Resources
Clerical & Administration
Community & Voluntary
Computers & ICT
Construction, Architecture & Property
Earth & Environment
Education & Teaching
Engineering, Manufacturing & Energy
Farming, Horticulture & Forestry
Fashion & Beauty
Food & Beverages
Government, Law & Education
Government, Politics & EU
Health care
History, Culture & Languages
Homemaker
Insurance
Law & Legal
Leisure, Sport & Fitness
Maritime, Fishing & Aquaculture
Media, Film & Publishing
Music & Performing Arts
Physics, Mathematics & Space Science
Psychology & Social Care
Sales, Retail & Purchasing
Security, Defence & Law Enforcement
Stay at home parent
STEM, Environment & Construction
Tourism & Hospitality
Transport & Logistics
Hours worked per week
Personal, Lifestyle, Social
Smoking
Are you?:
Current Smoker
Ex Smoker
Never Smoked
Do you / Did you smoke:
Cigarettes
Cigars
Pipe
E-Cig
Other
Never Smoked
How many do you / did you smoke daily?
If an ex-smoker, when did you cease smoking?
For how many years were you / have you been smoking?
Have you had a chest x-ray in the last 12 months
Alcohol
National Guidelines per week - 17 standard drinks for men, 11 standard drinks for women
A standard drink (SD) is a measure of alcohol that contains 10g of pure alcohol, for example:
A pint of 4.5% beer is 2 (SD), a pub measure of spirits (35.5ml) is 1 (SD) and a 100ml glass of 12.5% wine is 1 (SD).
Do you drink:
Beer
Wine
Spirits
Mix of above
Never Consumed Alcohol
Number of Units per week
Have you ever felt you need to cut down on your drinking:
Yes
No
Have you ever felt guilty about your drinking?:
Yes
No
Have people ever annoyed you by criticising your drinking:
Yes
No
Have you ever had a drink early in the day to steady your nerves?:
Yes
No
Exercise
Which of the following best describes how you exercise
Sedentary: Seldom or never exercise
Low Activity: Work in an office with some walking
Moderate Activity: Brisk 30 min walk, gardening, swimming or running for 3 or more days
Active: More than 30 minutes brisk walking, swimming, running 5 days or more a week
Diet
Dietary Information
Please indicate the number of times per week you eat or drink the following types of food:
Fried Foods:
0
1
2
3
4
5
6
Greater than 6
Full fat dairy, milk, cream, butter, cheese:
0
1
2
3
4
5
6
Greater than 6
Low fat dairy products:
0
1
2
3
4
5
6
Greater than 6
Chicken:
0
1
2
3
4
5
6
Greater than 6
Red meat:
0
1
2
3
4
5
6
Greater than 6
Fish:
0
1
2
3
4
5
6
Greater than 6
Cereals, bran, wholegrain:
0
1
2
3
4
5
6
Greater than 6
Fresh fruit:
0
1
2
3
4
5
6
Greater than 6
Fresh vegetables:
0
1
2
3
4
5
6
Greater than 6
Biscuits, sweets, cakes:
0
1
2
3
4
5
6
Greater than 6
Ready Prepared meals:
0
1
2
3
4
5
6
Greater than 6
Eating out in restaurants:
0
1
2
3
4
5
6
Greater than 6
Takeaways:
0
1
2
3
4
5
6
Greater than 6
Are you happy with your current weight
Yes
No
If yes, please explain
What do you think your ideal weight should be?
Give an example of your average days food intake
Breakfast:
Lunch:
Dinner:
Sleep Pattern
How many hours of sleep do you get in a night?
Do you snore loudly?
Yes
No
Do you snore every night?
Yes
No
Have you been told you hold your breath while sleeping?
Yes
No
Any sleep concerns?
Yes
No
Reviews Of Systems
Past medical / surgical history: Please indicate if you have a problem with any of the symptoms or conditions listed below.
If you answer 'Yes' to any question, please comment in the space provided.
General
Anaemia
Yes
No
Comments
Weight loss
Yes
No
Comments
Blood transfusion
Yes
No
Comments
Swollen glands
Yes
No
Comments
Fever/Chills
Yes
No
Comments
Migraine/Frequent headaches
Yes
No
Comments
Epilepsy
Yes
No
Comments
Difficulty with memory
Yes
No
Comments
Depression
Yes
No
Comments
Mental illness
Yes
No
Comments
If you answered Yes to the last 2 questions, please answer the following:
During the
last month
have you...
Have you been feeling down, depressed or hopeless?
Yes
No
Do you often have little interest or pleasure in doing things?
Yes
No
Have you ever felt suicidal?
Yes
No
Past medical / surgical history: Please indicate if you have a problem with any of the symptoms or conditions listed below.
If you answer 'Yes' to any question, please comment in the space provided.
Heart/Vascular
Do you have a history of Chest Pain/Pressure/Heart attack
Yes
No
Comments
Irregular heartbeat
Yes
No
Comments
High Blood pressure
Yes
No
Comments
Fainting/Lightheadedness/Dizziness
Yes
No
Comments
Varicose veins or Phlebitis
Yes
No
Comments
Bypass surgery
Yes
No
Comments
Coronary stent
Yes
No
Comments
High cholesterol
Yes
No
Comments
Pulmonary
Cough or phlegm
Yes
No
Comments
Coughed up blood
Yes
No
Comments
Breathlessness, other than with strenuous exercise
Yes
No
Comments
Asthma/pneumonia/bronchitis
Yes
No
Comments
Gastrointestinal
Heartburn/Acid reflux/Hiatus hernia
Yes
No
Comments
Loss of appetite
Yes
No
Comments
Ulcers
Yes
No
Comments
Nausea/vomiting
Yes
No
Comments
Unexplained weight loss
Yes
No
Comments
Abdominal pain
Yes
No
Comments
Constipation or diarrhea
Yes
No
Comments
Change in bowel habit
Yes
No
Comments
Blood in stools/Black stools
Yes
No
Comments
Haemorrhoids (piles)
Yes
No
Comments
Urinary
Increased frequency of urination
Yes
No
Comments
Getting up at night to urinate
Yes
No
Comments
Blood in urine
Yes
No
Comments
Pain/stinging when urinating
Yes
No
Comments
Leaking of urine during coughing or sneezing
Yes
No
Comments
Difficulty in starting or stopping urine flow
Yes
No
Comments
Kidney stones
Yes
No
Comments
(Men only) Problems having or sustaining an erection
Yes
No
Comments
Loss of libido
Yes
No
Comments
Declaration
I accept that a copy of my report will be sent to my GP. If any serious issues are identified, my GP and/or another consultant may be contacted directly. I also accept that if there are any abnormal results, I will be advised to attend my GP and/or Consultant for further management. I will be responsible for acting on that advice.
I understand that any follow up treatment with my GP and/or Consultant will be my own responsibility.
Comments
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