Conway PMS. NHS Health Check Questionnaire

Transcription

1 Conway PMS NHS Health Check Questionnaire We would be grateful if you could kindly complete this survey. Please be as honest as possible to help us to help you. Name: Male Female D of B: dd / mm / yyyy Ethnicity (please tick) White Asian or Asian British Any other Black background White British Indian Any other Ethnic Group White Irish Pakistani Chinese Any other white background Bangladeshi Irish Traveller Mixed Heritage Any other Asian Background Traveller White and Black Caribbean Black or Black British Gypsy/Romany White and Asian Black British Other White and Black African Caribbean Any other mixed race African Ethnic group not given Smoking Status - tick box(es) if YES and complete any additional information requested Non-smoker Ex Smoker Date Ceased: dd / mm / yyyy How many did you used to smoke per day? Current Smoker How many do you smoke per day? Do you smoke a pipe or cigars? Alcohol Intake This test helps us to work out your drinking habits. The questions are about your use of alcohol in the last year. Please score according to your answer. eg, if your Scores answer to Q1. is 2-4 times a month then your score is Score How often do you have a drink containing alcohol? Monthly or 2-4 times or more less a month times a times a week week How many drinks containing alcohol do you have on a 1 or 2 3 or 4 5 or 6 7 to 9 10 or more typical day when you are drinking? How often do you have 6 or more drinks on one occasion 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 of you because of drinking? How often during the last year have you needed a first 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? Have you or someone else been injured because of your drinking? Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested you cut down? No No Yes, but not in the last year Yes, but not in the last year Physical Activity and Diet How many hours per week do you spend walking outdoors or in sporting activities or other exercise (including heavy housework)? How may portions of fruit and vegetables do you eat per day (typically)? Yes during the last year Yes during the last year

2 Activity Related Questions 1. Please tell us the type and amount of physical activity involved in your work. Please tick one box that is closest to your present work from the following five possibilities Mark one box only a b c d e I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.) I spend most of my time at work sitting (such as in an office) I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.) My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.) My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.) 2. During the last week, how many hours did you spend on each of the following activities? Please answer whether you are in employment or not Please mark one box only on each row None Some but less than 1 hour 1 hour but less than 3 hours 3 hours or more a b c d e Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc. Cycling, including cycling to work and during leisure time Walking, including walking to work, shopping, for pleasure etc. Housework/Childcare Gardening/DIY 3. How would you describe your usual walking pace? Please mark one box only. Slow pace (i.e. less than 3 mph) Steady average pace Brisk pace Fast pace (i.e. over 4mph)

3 Your Family History Did / does any close relative (parents or siblings) have any of these diseases? Diabetes Stroke Peripheral Vascular Disease (Hardening of the Arteries) Angina Heart Attack Do you have any 1 st degree relatives with Diabetes also diagnosed with angina, stroke and/or heart attack when they were aged less than 55 yrs (for males) or 65 yrs (for females) Yes No Cancer Type (if known) Age when diagnosed Which Family member Early Detection and Support Have you ever been told by a doctor that you have high blood pressure? Yes No Have you ever been told by a doctor that you have high blood sugar (eg, in a health examination, during an illness or during pregnancy? Yes No Please list any over the counter medications that you purchase yourself on a regular basis (eg, pain killers, haemorrhoid treatments, indigestion remedies) General Questions Have you had any recent unexplained weight loss (not through dieting)? Do you have a persistent cough? Have you any recent bleeding from the back passage? Have you had chest pain / tightness / indigestion in the past few months? Do you get breathless walking about 100 yds / 90m on the flat? Do you feel depressed / low mood most days Men only When you pass urine does it take a while for it to start or is the flow interrupted? Do you have to get up in the night at least twice to pass urine and / or find you can t last more than an hour in the day without needing to go to the toilet? Do you have difficulty in maintaining or obtaining an erection? Women only Have you had any vaginal bleeding in between periods? Have you any bleeding after sex? If you have passed the menopause, have you had any vaginal bleeding since then? Have you had any recurrent breast pain or noticed any change in the shape of your breasts? Are you experiencing any problems with your home, such as keeping warm, dealing with repairs or hazards? If you care for someone in your family, a friend or a neighbour who could not manage without your help then you are a Carer. The person you care for may require your help due to frailty, illness, learning or physical

4 Mood Related Questions During the last month have you been feeling down, depressed or hopeless? During the last month have you often been bothered by having little interest or pleasure in doing 5 > over 65 s only Have you fallen in the last year If yes to the above qtn- please answer questions below Do you take more than 4 medications per daythings? Have you had a stroke or Parkinson s disease Do you have any problems with balance? Are you unable to get up from a chair of knee height?

5 BP: Pulse Rate: Clinicians use only HbA1c: Rhythm (reg/irreg): TC: HDL: TRG: LDL: TC: HDL ratio: JBS2 absolute risk:(%) Screening spirometry (FEV1/FVC): Lung Age: Height: (m) Weight (kg): BMI: Waist measurement: EtOH score: : GPPAQ score: FRAT score: Useful links for Discussion: Healthwise ext 2130 Refer to GHLiS ( ) for free stop smoking Greenwich Addiction Service GAS (inpatient) CRi Primary Care Drug & Alcohol Service (outpatient) Falls Team Tel: /2; Fax: ADMIN: Coded Faxed to GP Thank you for your time. Please remember to bring this completed form with you to your appointment