General Health Assessment

If you have been advised by the surgery to complete a General Health Assessment, please us this form.

General Health Assessment
Please use this date format: DD/MM/YYYY.

Smoking Status

Do you currently smoke? *
How many cigarettes do you smoke in a day? *
Would you like to give up smoking? *

Please visit NHS Stop Smoking for more information about giving up smoking.

Have you smoked in the past? *
How many cigarettes did you smoke in a day? *

Blood Pressure

Please use this date format: DD/MM/YYYY.