General health Review Form

General Health Review
Please use format day/month/year e.g. 12/05/1979

Height and Weight

Weight

Please provide details of your heigh and weight in either Metric or Imperial units.
Unit of measurement *
Choose your preferred unit of measurement.
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Blood pressure

Your reading is made up of 2 numbers.

Enter the highest number first. This is the highest level your blood pressure reaches when your heart beats (systolic).

Then enter the lower number. This is the lowest level your blood pressure reaches when your heart relaxes between beats (diastolic).

Your Personal Alcohol Consumption

Units of Alcohol

Your Personal Alcohol Consumption – Part 2

Smoking Status

Do you smoke?
How many cigarettes do you smoke a day?
Would you like help to quit smoking?
Do use an e-Cigarette

Health and fitness

How active are you?
Could you eat more healthily?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.