Severe Mental Illness – Health Check Questionnaire

Section

About You

If you have provided any of this information in the past month, then there is no need to do so today.

Are you able to provide your blood pressure?

Blood Pressure

Please enter your most recent blood pressure and pulse reading:

Please use this date format: DD/MM/YYYY
Are you able to provide your height?

Height

Are you able to provide your weight?

Weight

Have you noticed any changes in your weight? (For example: are your clothes fitting tighter or looser)
Are you able to provide your waist measurement?

Waist

Lifestyle

How is your diet?
How much exercise do you do weekly?
Have you recently made changes to your lifestyle? (For example: new diet, drinking less, smoking less)

Which of the following activities do you do? (Tick all that apply)
Do you use any illicit substances or non-prescribed drugs?

Smoking

Are you a current cigarette or vaporizer smoker? *
Would you like to give up smoking?

We advise that you contact Smokefree Norfolk for help quitting.

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *