Pre A nnual Health Check questionnaire Created: June 2020 in collaboration with Richmond Mencap and SWL CCG

 

 

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To help keep you healthy, your local doctor (your GP) would like to see you every year for an annual health check.   

The questions below will help you get the most out of your visit. Please try and fill it in as best as you can. 

At the end of your appointment, your doctor will give you a health action plan.

This will say what you, your carer and your doctors are going to do to help you stay healthy. 

If you have a health action plan from last year, please bring it with you. 

You can do it on your own, with your carer or ask your carer to do it for you.   

 

My name is

_________________________ My date of birth is

_________________________  My main carer Name: ______________________________________________ Relationship: ______________________________________________ Contact Details:  ______________________________________________  Do you have a social worker?   Yes ☐ No ☐ What is their name and phone number? ________________________________________________________________ Who do you live with? Name Relationship (mum, friend, carer etc.)

 Who are the other important people in your life? Name Relationship (brother, friend,

girlfriend)

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A – ABOUT YOU

Do you have a job? Yes ☐ No ☐

If Yes, what is your job?

_____________________________________

If Yes, how long do you work for?

1-8 Hours ☐ 9-16 Hours ☐ 16+ Hours ☐ Not Sure ☐

How do you like to talk? 

Talking ☐ Sign Language ☐ Gestures ☐ Communication aid ☐

Not Sure ☐ Other ______________________________________

Is there anything that would help you with the doctor? e.g. having a carer with me, having a longer appointment

________________________________________________________________ Do you have any worries about going to health appointments? e.g. waiting , loud noises, I need someone with me to go to appointments, I am scared of needles

________________________________________________________________

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B – DAILY LIFE

Do you need help with any of these things? If yes then what help do you need?

Moving about Yes ☐ No ☐

Eating Yes ☐ No ☐

Drinking Yes ☐ No ☐

Getting dressed

Yes ☐ No ☐

Washing Yes ☐ No ☐

Going to toilet

Yes ☐ No ☐

Please turn to next page

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What did you eat and drink yesterday? 

Breakfast:Lunch:Dinner:Snack:

What exercise have you done over the last week? 

MondayTuesday

WednesdayThursday

FridaySaturdaySunday

 Do you smoke? Yes ☐ No ☐

Do you drink alcohol? Yes ☐ No ☐

Have you ever had sex? Yes ☐ No ☐

 

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C - HEALTH

D – HEALTH APPOINTMENTS

When did you last go to the dentist?

____________________________________________

You should go to the dentist every year!

When did you last go to the optician?

____________________________________________

You should go to the optician every two years!

When did you last have your hearing tested? 

________________________________________

   

Do you or your carer have any worries about your health at the moment? 

________________________________________________________________ Has your carer noticed any changes in behaviour?

________________________________________________________________

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E- YOUR HEALTH NOW

These questions are about your heart and chest

Do you have a cough? YES ☐    NO ☐Do you have trouble breathing? YES ☐    NO ☐Do you ever get chest pain? YES ☐    NO ☐Do you ever feel your heart beating fast or strangely? YES ☐    NO ☐

Do you have problems swallowing? YES ☐    NO ☐

These questions are about eating and going to the toilet.

Do you get pain or feel sick after eating? YES ☐    NO ☐

Do you do a poo every day? YES ☐    NO ☐Does it hurt to do a poo? YES ☐    NO ☐Have you noticed blood in your poo? YES ☐    NO ☐Do you do runny poos? YES ☐    NO ☐Do you have accidents with poos? YES ☐    NO ☐Does it hurt when you wee? YES ☐    NO ☐Do you need to get up a lot in the night to wee?

YES ☐    NO ☐

Do you have blood in your wee? YES ☐    NO ☐Do you ever have accidents with wees? (incontinence)

YES ☐    NO ☐

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These questions are about pain you may feel on your body

Do you have any swelling of your feet or ankles? YES ☐    NO ☐Do you have any pain anywhere? YES ☐    NO ☐Do you have any pain when you walk or move? YES ☐    NO ☐Do you have any skin problems? YES ☐    NO ☐

These questions are about how you are feeling

Do you feel sad a lot of the time? YES ☐    NO ☐Do you ever hurt yourself or others? YES ☐    NO ☐Do you feel anxious or worried? YES ☐    NO ☐Do you or your carer think there has been a change in your memory? YES ☐    NO ☐

Do you have any trouble sleeping? YES ☐    NO ☐

FOR MEN ONLY 

Do you know how to examine your own testicles?  Yes ☐ No ☐ FOR WOMEN ONLY

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Do you have periods? YES ☐    NO ☐Do you have periods every month?

YES ☐    NO ☐

Are your periods painful or heavy?

YES ☐    NO ☐

 Have you noticed any pain or lumps in your breasts? Yes ☐ No ☐

If you are over 50, have you been for a breast screening test? Yes ☐ No ☐

When was you last test? ____________________________________

Do you know how to examine your own breasts? Yes ☐ No ☐ If you are aged 25 to 64 have you had a cervical smear test? Yes ☐ No ☐

When was your last test? __________________________________

FOR PEOPLE WITH EPILEPSY ONLY

If you have epilepsy have you had any seizures this year? 

_________________________________________ How many seizures do you have? Once a year ☐    Once a month ☐  Once a week ☐ Once a day ☐ Other ___________________________________________

This is the end of the questions.9

Thank you for filling out this form!

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