General health questionnaire

Have you been asked by the practice to complete this online review form? Required

Yes

No

Please do not fill this form in until you have been asked to complete it by the GP surgery. If you have not been asked to submit this form, you will need to discuss it with the surgery first.

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

BMI

Height (in Meters) Required

e.g 1.75

Weight (in Kilograms) Required

e.g 60.6

BMI:

Please note: BMI calculator is only for patients aged 18 and over.

Blood Pressure

Please give your latest home Blood Pressure reading if available:

Systolic “Higher”

Diastolic “Lower”

Smoking Status

Please select your smoking status: Required

Current Smoker

Ex-Smoker

Never Smoked

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

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

How often do you have a drink containing alcohol? Required

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? Required

Exercise

Are you physically active? Required

Yes

No

Diet

How would you describe your diet? Required

Good/healthy

Balanced

Poor

How would you describe a healthy diet? Required

Tell us whether you accept cookies

BMI