• YOUR HEALTH ASSESSMENT QUESTIONNAIRE

  • Your personal details

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  • 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:
  • Clear
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  • 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
  • YOUR JOB HISTORY

    If you are in employment please answer the following questions:
  • YOUR LIFESTYLE

    Your exercise and activity
  • Your Diet
  • Smoking
  • Alcohol
  • Your Medical History

    Have you ever had any of the following ? If yes, please give details and dates as appropriate.
  • YOUR MEDICAL HISTORY

    Have you ever had any condition that has needed treatment from your doctor ?
  • Also
  • 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?
  • 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.
  • 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.
  • HEALTH QUESTIONS FOR MEN

  • HEALTH QUESTIONS FOR WOMEN

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  • Should be Empty:
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