• YOUR HEALTH ASSESSMENT QUESTIONNAIRE

  • Your personal details

  • Date of Birth
     - -
  • Are you covered by private medical insurance?
  • Date questionnaire completed
     - -

  • Please complete the following if your employer is paying for this assessment:

  • KEEPING YOUR GP INFORMED AND MONITORING FURTHER ACTION

    It is good practice for your GP to be kept informed of all aspects relating to your health. Please complete the information bellow if you are happy for us to send your GP an abbreviated version of your report and advise him or her of any abnormalities or significant results that may require follow-up investigation or treatment.

  • BHC monitors what happens to customers after certain screening tests and certain abnormal results. This allows us to check on the quality of these tests and ensure that any necessary action has taken place. Please indicate whether or not you are happy for us to contact the following:
  • You
  • Your GP
  • Date filled
     - -

  • PLEASE TELL US YOUR MAIN REASONS FOR ATTENDING

  • If you have any specific areas of concern, please list them in priority order

  • Your assessment includes a large number of tests covering a wide range of medical conditions. As with most medical tests and services, it is not always possible to detect all diseases and abnormalities. You should be aware that this assessment is aimed at offering advice and insight into your lifestyle and offering adaptions where required to enable you to seek better health and well being. If however, any medical symptoms you have do not resolve as expected or any new symptoms arise, you should seek further medical advice.

  • PLEASE TELL US ABOUT YOURSELF AND YOUR FAMILY

    Material status
  • Are you:
  • Spouse's health

  • YOUR JOB HISTORY

    If you are in employment please answer the following questions:
  • Do you take your full holiday allowance?

  • YOUR LIFESTYLE

    Your exercise and activity
  • How much aerobic exercise do you take? (By aerobic exercise we mean continuous bodily activity sufficient to increase your breathing rate moderately)
  • Are you a member of a gym?
  • Are you generally active as part of your daily routine? eg. do you walk a lot, do you use the stairs instead of the lift, are you a keen gardener?

  • Your Diet
  • Do you limit the amount of refined sugar in your diet? eg sugar, sweets, biscuits, chocolate, cakes
  • Do you eat foods high in fibre on a daily basis? eg wholemeal bread, pulses and lentils, high fibre breakfast cereals,and generally unrefined wholemeal foods such as brown rice and brown pasta.
  • Do you limit your intake of saturated fat? eg butter, cream, cakes, eggs and fatty meats
  • Do you eat five or more portions of fruit and/or vegetables each day?
  • Do you eat more fish and poultry than red meat?
  • Do you drink about 2 to 2.5 litres of fluid a day? (this includes fluids contained within food) Most people with a moderate activity level and in a moderate temperature have about 2 to 2.5 litres of fluid a day (about seven to eight medium-sized glasses).
  • How many cups of caffeinated tea and coffee do you drink a day?
  • Has your weight been steady recently?

  • Smoking
  • Do you smoke?
  • If you are a non-smoker, are you regularly exposed to a smoky atmosphere?

  • Alcohol
  • How often do you drink alcohol?

  • Your Medical History

    Have you ever had any of the following ? If yes, please give details and dates as appropriate.
  • Stroke
  • Deep vein thrombosis
  • Kidney problems, stones
  • Cystitis (urine infection)
  • Bronchitis, Emphysema
  • Asthma
  • Tuberculosis
  • Pneumonia, pleurisy
  • Peptic ulcer, indigestion
  • Jaundice, hepatitis
  • Gallstones
  • Piles or fissures
  • Polyps in colon
  • Colitis, irritable bowel
  • Diabetes
  • Thyroid problems
  • Mumps
  • Blood disorder eg anaemia
  • Malaria
  • Other tropical diseases
  • Mental problems
  • Depression
  • Anxiety
  • Fits, epilepsy, blackouts
  • Migraine, recurrent headaches
  • Concussion, head injury
  • Cancer
  • Other glandular disorders
  • Problems with veins, varicose veins
  • Glaucoma
  • Ear disease or discharge
  • Skin problems eg eczema
  • Back problems
  • Arthritis, gout
  • Bone fractures, osteoporosis
  • Muscle or nerve disease
  • Sexually transmitted infections eg chlamydia
  • Prostate or bladder problems
  • Hernia operation
  • Any other operations
  • Accident, injuries
  • Sterilisation, vasectomy
  • Blood transfusion

  • YOUR MEDICAL HISTORY

    Have you ever had any condition that has needed treatment from your doctor ?
  • Your heart, including blood pressure?
  • Your lungs - for instance pneumonia, asthma, bronchitis?
  • Your abdomen - for instance peptic ulcer, hiatus hernia, irritable bowel syndrome?
  • Your kidneys or bladder - for instance kidney stones, urinary infection or cystitis?

  • Also
  • Have you ever had a fit or fainted?
  • Have you ever had a stroke or "mini-stroke"?
  • Have you ever had or do you have diabetes or any other endocrine (glandular) problems?
  • Have you ever had any periods of anxiety or depression that have interfered with the way you lead your life?
  • Have you ever had any form of cancer?
  • If you are a woman, have you had any breast or gynaecological problems?

  • In the past year, have you suffered from or been unable to work because of the following :

    if yes, approximately how many days were you unable to work?
  • Back pain
  • Other muscle or joint pain
  • Colds, influenza, virus infection
  • Headaches
  • Period pain, Pre-menstrual syndrome (PMS)
  • Gastric problems (nausea, diarrhoea, vomiting)
  • Stress
  • Other illnesses
  • Injury
  • Accidents
  • Assault

  • YOUR WELLBEING

    Please read this carefully. We would like to now how your health has been in general, over the past few weeks. Please answer ALL the questions by putting a tick in the box indicating the answer which you think most applies to you.
  • Been able to concentrate on whatever you're doing?
  • Lost much sleep over worry?
  • Felt you were playing a useful part in things?
  • Felt capable of making decisions about things?
  • Felt constantly under strain?
  • Felt you couldn't over come your difficulties ?
  • Been able to enjoy your normal day-to-day activities ?
  • Been able to face up to your problems?
  • Been feeling unhappy or depressed?
  • Been losing confidence in yourself?
  • Been thinking of yourself as a worthless person ?
  • Been feeling reasonably happy, all things considered?

  • ABOUT YOUR WORK

    If you are in employment, for each question indicate the one answer that best describes your job or the way you deal with problems occurring at work. Please answer ALL the questions.
  • Do you have to work very fast?
  • Do you have to work very intensively ?
  • Do you have enough time to do everything?
  • Do you have the possibility of learning new thing through your work?
  • Does your work demand a high level of skill or experience?
  • Does your job require you to take the initiative?
  • Do you have to do the same thing over and over again?
  • Do you have a choice in deciding how you do your work?
  • Do you have a good deal of say in decisions about work?
  • Do you find your job satisfying and fullfilling?

  • HEALTH QUESTIONS FOR MEN

  • Do you regularly examine your testes?
  • Have you ever notices any lumps or swellings in your testes ?
  • Do you get up at night to pass urine on a regular basis?
  • Have you noticed any change in the flow rate or stream of your urine?
  • Do you have difficulty in starting and stopping passing urine?
  • Do you have any problems with sexual function?

  • HEALTH QUESTIONS FOR WOMEN

  • Are your breasts aware and do you know how to examine your breasts?
  • Do you have any problems with your periods?
  • When was your last period?
     - -
  • When was your last cervical smear ?
     - -
  • Have your recent periods been regular?
  • Are pre-menstrual symptoms a problem?
  • Do you have any sexual problems?
  • Do you have any bleeding between periods of after intercourse?
  • Would you like to discuss hormone replacement therapy?
  • Should be Empty: