Annual Review: Holistic Health Questionnaire
Please complete this form before your annual review appointment. It helps us understand how you're doing and make the best use of your appointment time.
SECTION 1 - About You
Name:
*
First Name
Last Name
Date of birth:
*
/
Day
/
Month
Year
Contact number:
*
Do you have a carer?
*
Yes
No
Please provide carer details (name, address, contact number)
Consent for record sharing:
*
Consent given for record sharing
No consent given for record sharing
Current employment status:
*
Full-time employment
Part-time employment
Unemployed
Student
Retired
If employed, what is your job role?
SECTION 2 - Social Circumstances
How would you describe your living situation?
*
Lives alone
Lives with family
Lives with partner
Lives with friend
Lives in sheltered housing
Lives with lodger
Other
Do you have any concerns about your living conditions?
*
Yes
No
What concerns do you have about your living conditions?
Do you feel lonely or socially isolated?
*
Yes
No
Are you managing to keep your home warm enough?
*
Yes
No
Do you have a smoke alarm at home?
*
Yes
No
Do you have a carbon monoxide monitor at home?
*
Yes
No
How would you describe your financial situation?
*
Financial problems
Financially poor
Needs help managing financial affairs
Able to handle money
SECTION 3 - Your Health
Are you managing ok to move around the house?
*
Fully mobile
Mobile in home
Reduced mobility
Use of indoor mobility aids
Confined to chair
Bed-ridden
Have you had many falls in the last year?
*
No
Yes (please tell us how many)
During the last month have you often been feeling down, depressed or hopeless?
*
Yes
No
During the last month have you often been bothered by having little interest or pleasure in doing things you enjoy?
*
Yes
No
Are you taking all your prescribed medicine as advised?
*
Yes
No
Do you have any concerns about your medication?
*
No
Yes (please explain your concerns)
Do you currently smoke?
*
No
Yes (please advise how much you smoke per day)
Would you like any help or advice on stopping smoking?
*
Yes
No
Do you drink alcohol?
*
No
Yes (please advise how many units per week)
What is your activity level?
*
Gets no exercise
Enjoys heavy exercise
Enjoys moderate exercise
Enjoys light exercise
Exercise physically impossible
Submit
Should be Empty: