Submit my NHS Healthcheck Please note: if any part of the form is not completed accurately the form will be discarded and not submitted for review. (BP readings can be done at most gyms and some pharmacies or using a relative's machine. Alternatively BP monitors can be purchased via dispensary for £22.) Please only submit your form once you have been to have your blood taken. Please do not forget to drop a urine sample in to the surgery. About YouName* First Last Date of Birth* Date Format: DD slash MM slash YYYY Mobile Phone Number*Email* Section BreakYour NHS HealthcheckBlood pressure reading - form will be discarded and not submitted for review if not completed accurately*BP readings can be done at most gyms and some pharmacies or using a relative's machine. Alternatively BP monitors can be purchased via dispensary for £22.Pulse (beats per minute)*This will either be shown on the BP machine or can be checked by counting the beats in 1 minute using the radial pulse.Height (cms)*Weight (kgs)*Approximately how many units of alcohol do you consume each week?*1 unit of alcohol is equal to a 25ml single measure of whisky, a third of a pint of beer or half a standard (175ml) glass of wine.Approximately how long do you spend on physical activity each week?*Inactive - Less than 30 minutes a weekModerately active - Between 30 and 60 minutes a weekActive - Between 60 and 150 minutes a weekWhat type of exercise do you do if any?*Smoking status*SmokerEx smokerNever smokedHow many do you smoke per day?*25g of tobacco = 7 cigarettesWould you be interested in receiving smoking cessation advice?*YesNoWhen did you give up smoking?*Do you have any concerns regarding your memory?*YesNoPlease specify*Section BreakDo you have a family history of the following?Ischaemic heart disease*YesNoAngina in 1st degree female relative <65yrs*YesNoAngina in 1st degree male relative <55yrs*YesNoHeart attack in 1st degree female relative <65yrs*YesNoHeart attack in 1st degree male relative <55yrs*YesNoDiabetes*YesNoRaised Cholesterol*YesNoIs there any other family history you think may be relevant?