Health-Evaluation-Form

1
Name* This field is required.
First Name
Last Name
2
Gender* This field is required.
Male
Female
3
Email
example@example.com
4
Phone Number
Area Code
Phone Number
5
Do you Smoke?* This field is required.
Yes
No
Previously
6
What do you smoke?
Shisha
Tobacco
Cigarettes
Cigars
Electronic cigarette
7
How long have you smoked for?
8
How many per day?
9
Are you interested in stopping smoking?
YESNO
10
Do you drink alcohol?
YESNO
11
How often do you drink alcohol?
Daily
1-2 times a week
3-4 times a week
Weekly
Monthly
No I Don't Drink
12
How many units of alcohol?
Units
Alcopop (275ml) - 1.5 Units
Small glass of wine 125ml - 2 Units
Bottle of lager/beer/cider 330ml - 1.7 Units
Can of lager/beer/cider 440ml - 2 Units
Pint of lower-strength lager/beer/cider - 2 units
Standard glass of red/white/rosé wine 175ml - 2.1 Units
Pint of higher-strength lager/beer/cider - 3 Unit
Large glass of red/white/rosé wine 250ml - 3 Units
Alcopop (275ml) - 1.5 Units
Small glass of wine 125ml - 2 Units
Bottle of lager/beer/cider 330ml - 1.7 Units
Can of lager/beer/cider 440ml - 2 Units
Pint of lower-strength lager/beer/cider - 2 units
Standard glass of red/white/rosé wine 175ml - 2.1 Units
Pint of higher-strength lager/beer/cider - 3 Unit
Large glass of red/white/rosé wine 250ml - 3 Units
Units
Units
Units
Units
Units
Units
Units
Units
1 of 8
13
How often do you exercise?
Daily
1-2 times a week
3-4 times a week
4-6 times a week
I don't any exercise
14
What type of exercise you do?
Walking
Running
Golf
Gym
Other
15
How many portions of Fruit/Vegetables do you eat per day?
0
1-2
3-4
4-5
More than 5
16
Do you feel stressed due to your work, home life or financial pressures?
Yes
No
Intermittently
Regularly
17
Do you wish to discuss this further?
YESNO
18
If Yes
are you low in mood
are you suffering from anxiety
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling tired and or having little energy
Feeling bad about yourself
Trouble concentrating on things
Poor appetite or overeating
19
Have you ever suffered from? (Please tick relevant boxes)
Heart attack or Angina
Diabetes
Rheumatic Fever
High Blood Pressure
High Cholesterol
Asthma
Bronchitis / Emphysema
Thyroid Disorder
Allergies
Migraine
Blackouts / Seizures
Stroke / Mini – stroke
Cancer
Traumatic Injury / broken bones
Previous surgeries
Other / Comments
20
Provide further information
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Large
Normal
Small
Ok
Ok
21
If you have a family history of any of the conditions, please provide details below
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Large
Normal
Small
Ok
Ok
22
If selected Other
23
If you have ever been hospitalised in the past or had any operations / Surgical procedures, please provide details below
Huge
Large
Normal
Small
Ok
Ok
24
Please list any prescribed medication that you are currently taking. And also include any over the counter treatments such as herbal remedies
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Small
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Ok
25
Do you regularly examine your testicles?
Yes
No
26
If NoWould you be interested in learning?
27
Have you ever had any lumps or swelling in your testicles?
Yes
No
28
Do you get up at night to pass urine on a regular basis?
Yes
No
29
If yes, how many times a night?
30
Have you noticed any change in the flow, rate or stream of your urine?
Yes
No
31
Do you ever have a prostate examination / PSA (prostate) blood test?
Yes
No
32
Do you have pain on passing urine?
Yes
No
33
Have you ever noticed blood in your urine?
Yes
No
34
Do you ever have any problems with erections?
Yes
No
Intermittently
Regularly
35
Would you like to discuss anything related to sexual health?
Yes
No
36
Have you ever had a cervical smear test?
Yes
No
37
If yes was your most recent one normal?
Yes
No
38
Are you registered with Cervical Check program?
Yes
No
Don't Know
39
Do you regularly examine your Breasts?
Yes
No
40
If NoWould you like to learn how?
41
Have you ever noticed any lumps or swelling in your breasts?
Yes
No
42
Have you ever had a mammogram?
Yes
No
43
If yes was your most recent one normal?
Yes
No
44
Are you registered with Breast Check program?
Yes
No
45
When was your last period?
Date
Year
Month
Day
46
Have you ever been pregnant?
Yes
No
47
Fertility
Do you have any fertility concerns?
Have you activily tried to become pregnant?
48
How many children or births have you had?
49
Are you currently using contraception?
Yes
No
50
If yes what type?
51
Are you concerned about menopausal symptoms?
Yes
No
52
Are your periods irregular, particularly painful or heavy?
Yes
No
Not applicable
53
Have you experienced any vaginal bleeding / discharge that you think is abnormal?
Yes
No
54
Do you ever have difficulty controlling your bladder / getting to the toilet in time?
Yes
No
55
Would you like to discuss anything related to sexual health or infertility?
Yes
No
56
Please provide further information?
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Small
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57
Do you have a normal bowel movement?
YESNO
58
Any recent changes in bowel movements?
YESNO
59
Have you noticed any blood, mucus, change in color?
YESNO
60
Is there any other aspect of your health that you would like to discuss?
Yes
No
61
If yes, please provide details below
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Small
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Ok
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