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45-49 year old Health Assessment Pre Appointment Questionnaire
45-49 year old Health Assessment Pre Appointment Questionnaire
45-49 year old Health Assessment Pre Appointment Qustionnaire
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To assist us in completing your 45-49 year old health check we ask that you please complete the following questions before you arrive at the practice for your appointment.
Title
Dr.
Mr.
Mrs.
Ms.
Miss
Gender
Male
Female
Intersex
Rather not disclose
Name
First
Middle
Last
Date of Birth
DD
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MM
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YYYY
2025
2024
2023
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1931
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1928
1927
1926
1925
1924
1923
1922
1921
1920
How would you describe your current health?
Excellent
Very Good
Good
Fair
Poor
What do you see as your current health problems/concerns?
please list
Assessment of Nutrition
Do you eat 4-6 vegetables most days?
Yes
No
Do you think you are eating iron rich foods regularly?
Yes
No
Do you have any concerns about your diet?
Yes
No
Has your weight been generally consistent?
Yes
No
Are you concerned about your weight?
Yes
No
Do you have regular dental check ups?
Yes
No
Alcohol and Smoking
How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times per month
2-3 times per week
4+ times per week
How many standard drinks do you have on a typical day when you are drinking?
1-2
3-4
5-6
7-9
10+
How often have you had 6 standard drinks for more (female) or 8 standard drinks or more (men) on a single occasion in the last year?
Never
Less than monthly
Monthly
Weekly
Daily
Are you concerned about your drinking habits?
Yes
No
Do you currently smoke tobacco?
Yes
No
Quantity per day
If you have EVER smoked, when did you quit?
Sleep Assessment
On average, how many hours of sleep do you get per night?
Do you have trouble sleeping?
Yes
No
Has anyone complained that you snore loud enough to be heard through closed doors or disturb your partner?
Yes
No
Do you often feel tired, fatigued or sleepy during the day time?
Yes
No
Has anyone observed you stop breathing, choking or gasping while you were sleeping?
Yes
No
Physical Activity Assessment
Do you do exercise for 30minutes most days of the week?
Yes
No
How often do you exercise?
Daily
2-3 times per week
Once per week
Rarely
Mental Health
How do you consider your current stress levels to be?
No stress at all
Low
Medium
High
How would you rate your current mental health out of 10?
With 1 = I feel terrible and 10 = I feel fantastic
Depression and Anxiety
In the past 4 weeks, please tick the comment for each question that best describes how you have been feeling.
How often did you feel tired out for no good reason?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel nervous?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel so nervous that nothing would calm you down?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel hopeless?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel restless or fidgety?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel so restless you could not sit still?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel depressed?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel everything was an effort?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often did you feel so sad that nothing could cheer you up?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
How often do you feel worthless?
1 None of the time
2 A little of the time
3 Some of the time
4 All of the time
Family History
Has anyone in your close family suffered from the following? (Please state the relative affected e.g. mother, father, sister, brother, maternal grandmother, paternal grandfather)
Are your parents alive?
Yes
No
If no, what age were they when they passed away and what was their cause of death
Has anyone in your close family ever suffered from the following – Currently or in the past?
*
Heart Attack
Bowel Cancer
High Blood Pressure
Ovarian Cancer
Stroke
Cervical Cancer
Blood Clot(s)/DVT
Uterine Cancer
High Cholesterol
Prostate Cancer
Diabetes
Skin Cancer
Thyroid Disease
Any other cancer
Breast Cancer
Depression
Schizophrenia
Arthritis
None of the above
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Relative
Others, please list
Diabetes Risk
Have you ever been found to have high blood pressure?
Yes
No
Are you taking medication for high blood pressure?
Yes
No
Ladies; Did you suffer from gestational diabetes?
Yes
No
Osteoporosis Risk
Have you ever had a bone fracture after a minor bump or fall?
Yes
No
Do you consume 3-4 serves of calcium rich foods each day?
Yes
No
Ladies; Did you undergo menopause before the age of 45?
Yes
No
Ladies; Has your period ever stopped for more than 12 months or more (other than because of pregnancy)?
Yes
No
Skin
Do you have regular skin checks?
Yes
No
Do you have fair skin or blue or green eyes?
Yes
No
Have you ever been diagnosed with skin cancer?
Yes
No
Preventative Health
Are you up to date with your adult vaccinations such as whooping cough, tetanus, measles, flu?
Yes
No
Unsure
Men's Health
Do you regularly examine your testicles?
Yes
No
Have you ever had any lumps or swelling in your testicles?
Yes
No
Do you get up at night to pass urine on a regular basis?
Yes
No
If yes, how many times per night (on average)
Have you noticed any change in the flow, rate or stream of your urine?
Yes
No
Do you ever have any problems with erections?
Yes
No
Are there any sexual concerns you would like to discuss?
Yes
No
Women's Health
When was your last Pap Smear or cervical screening test?
Do you have regular mammograms?
Yes
No
Do you ever wonder if you are approaching menopause?
Yes
No
What frequency are your cycles (if applicable)
Do you have any concerns about heavy periods?
Yes
No
Do you require any information on contraception?
Yes
No
Are there any sexual concerns you would like to discuss?
Yes
No
Do you have any issues with urine or bowel incontinence or leakage?
Yes
No
Thank you for taking the time to complete these questions, your form will be emailed to our nursing team and passeed onto your GP prior to your appointment. All information collected, recorded and stored within this form is used in accordance with our under our privacy policy.
I, (insert name), confirm that the information supplied on this form are true and correct to my knowledge.
*
