81 Elborough Street, London, SW18 5DS. Phone: (020) 8874 7113

Patient Lifestyle Questionnaire

Elborough Street Surgery / Patient Lifestyle Questionnaire

Patient Lifestyle Questionnaire

If you would like to see a full page version of The Patient Lifestyle Questionnaire, click here.
Please note that all fields marked with an * require an entry.

Patient Lifestyle Questionnaire
  • Personal Details
    0
  • Name*full name
    1
  • Gender*
    Male
    Femail
    2

  • Date of Birth

    3
  • Day*
    4
  • Month*
    5
  • Year*
    6

  • Height

    7
  • Feet*
    8
  • Inches*
    9

  • Weight

    10
  • Stone*st
    11
  • Pounds*lbs
    12
  • Smoking
    13
  • Do you smoke?*Cigarettes / Pipe / Cigar
    Yes
    No
    14
  • How many a day?*
    15
  • Are you ready to give up?*
    Yes
    No
    16
  • Have you ever smoked?*
    Yes
    No
    17
  • When did you stop?
    18
  • Month*
    19
  • Year*
    20
  • Alcohol
    21
  • Each of these equals ONE unit: 1/2 pint ordinary beer or cider 1/4 pint strong beer 1 standard glass of table wine 1 standard glass of sherry 1 single measure of spirits
    22
  • How many units of alcohol do you drink per week?*
    23
  • Exercise
    24
  • In an average week how often do you exercise?*Please select one
    Two or more 40 minute sessions a week
    Two or more 30 minute sessions a week
    Once a week, for about an hour
    When I've got time
    None at all
    25
  • Health
    26
  • Have you ever had any of the following illnesses or conditions?
    27
  • Diabetes*
    Yes
    No
    28
  • High Blood Pressure*
    Yes
    No
    29
  • Heart Attack or Angina*
    Yes
    No
    30
  • Stroke*
    Yes
    No
    31
  • Have any of your close family had any of the following illnesses or conditions?
    32
  • Diabetes*
    Mother
    Father
    Brother(s)
    Sister(s)
    None to my knowledge
    33
  • High Blood Pressure*
    Mother
    Father
    Brother(s)
    Sister(s)
    None to my knowledgeowledge
    34
  • Heart Attack*
    Mother
    Father
    Brother(s)
    Sister(s)
    None to my knowledge
    35
  • Angina*
    Mother
    Father
    Brother(s)
    Sister(s)
    None to my knowledge
    36
  • Stroke*
    Mother
    Father
    Brother(s)
    Sister(s)
    None to my knowledge
    37
  • If known please give the age the condition started.
    38
  • Relative*
    39
  • Condition*
    40
  • Age*
    41
  • Relative*
    42
  • Condition*
    43
  • Age*
    44
  • Relative*
    45
  • Condtion*
    46
  • Age*
    47
  • Relative*
    48
  • Condition*
    49
  • Age*
    50
  • Any Additional Information*
    51
  • This information will be stored in our computer system. We are registered under the Data Protection Act.
    Thank you for taking the time to comlete this form.     Please click the 'Submit' button below when you are ready
    52
  • 53

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Surgery News

Our Address

81 Elborough Street
London
SW18 5DS
Phone: 0208 874 7113
Email: waccg.elboroughstreetsurgery@nhs.net

 

Surgery Hours

Monday 08.00 - 20.00
Tuesday 08.00 - 18.30
Wednesday 08.00 - 18.30
Thursday 08.00 - 20.00
Friday 08.00 - 18.30
Saturday 09.00 - 12.00
Evening & Saturday Surgery
Evening (18.30 - 20.00) and Saturday surgery are pre booked appointments only

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