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Tamworth House Medical Centre NHS GP Surgery in Surrey

Carers annual health check assessment

Carers Annual Health Check Assessment

Section

Blood Pressure

Systolic “Higher”

Diastolic “Lower”

Heart Rate

Date:

Please use this date format: DD/MM/YYYY.

Lifestyle

Do you currently smoke?

Current Smoker

Ex Smoker

Never Smoked

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Height:

Weight:

Alcohol Consumption

One unit of alcohol

Amount of different types of drink representing one unit of alcohol

More than one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Further Information

Do you feel happy?

Yes

Do you feel supported?

Yes

Have you had a flu jab?

Yes

Do you have any health concerns about yourself?

If you are human, leave this field blank.

Tamworth House Medical Centre
341 Tamworth Lane
Mitcham
Surrey
CR4 1DL

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020 8764 2666

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