General Health Questionnaire

If you have been advised to submit a General Health Questionnaire, please submit this form.

General Health Questionnaire

General Health Questionnaire

Section

Ethnicity

Please specify the ethnic group you consider you belong to: *
*
*
*
*
*

Blood Pressure

Smoking

Smoking Status: *
Would you like help to give up smoking?

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

If you have any health concerns that are not related to your long term condition please contact the surgery and arrange an appointment or contact 111.