Annual Physical Review

Section

About You

If you have provided any of this information in the past month, then there is no need to do so today.

Are you able to provide your blood pressure?

This information can be collected during your face-to-face appointment.

Blood Pressure

Please enter your most recent blood pressure and pulse reading:

Please use this date format: DD/MM/YYYY
Are you able to provide your height?

This information can be collected during your face-to-face appointment.

Height

Are you able to provide your weight?

This information can be collected during your face-to-face appointment.

Weight

Have you noticed any changes in your weight? (For example: are your clothes fitting tighter or looser) *
Are you able to provide your waist measurement?

This information can be collected during your face-to-face appointment.

Waist

Lifestyle

Have you recently made changes to your lifestyle? (For example: new diet, drinking less, smoking less) *

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 alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

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 from you because of your drinking? *
How often during the last year have you needed an alcoholic 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? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Smoking

Smoking status: *
Would you like to give up smoking? *

We advise that you contact Smokefree Norfolk for help quitting.

Which of the following activities do you do? (Tick all that apply)
How often do you complete at least 30 minutes of physical activity? *
Do you use any illicit substances or non-prescribed drugs? *

Next Steps

A face-to-face appointment may be needed to complete your review. This will include a blood test.

Do you already have a face-to-face review booked? *