Gold Street Surgery Health Check Form
Patient Details
*What Is Your Height: ………………………………………………………………………………..
*What Is Your Weight: ……………………………………………………………………………….
*Do You Smoke:
Yes / No
How Many Per Day: ………………………………………………………………………………….
*Ever Smoked:
Yes / No
How Many: …………………………………………………………………………………………….
Date Stopped (dd/mm/yyyy):………..……………………………………………………………….
*Are You A Carer:
Yes / No
To whom (Name & relationship): ……………………………………………………………………
*Do You Have Any Of The Following:
Heart Failure
Mental health problems
CHD
Asthma
Stroke or TIC
Chronic kidney disease
Hypertension
Atrial fibrillation
Diabetes
Obesity
Cancer
Learning difficulties
In need of palliative care
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
/
/
/
/
/
/
/
/
/
/
/
/
/
No
No
No
No
No
No
No
No
No
No
No
No
No
*List Current Medications: ……………………………………………………………………………
………………………………………………………………………………………………..................
………………………………………………………………………………………………..................
………………………………………………………………………………………………..................
*Drug Allergies: ………………………………………………………………………………………..
………………………………………………………………………………………………..................
………………………………………………………………………………………………..................
………………………………………………………………………………………………..................
………………………………………………………………………………………………..................