Carers Annual Health Check

You have been asked to complete this form as we have you recorded as a carer on your medical notes. If this is not the case, please accept our apologies and inform your doctor's secretary so we can amend your record. By completing this questionnaire you are completing your Carers Annual Health Check. Your responses will be reviewed and if there are any concerns highlighted a telephone consultation with a clinician will be booked for you. If you have any specific concerns about anything to do with yourself or the person you care for, please contact your doctor's secretary.

Last Updated: 13/04/2021

Personal Details



Blood Pressure Readings

Please use the section below to provide up to three recent blood pressure readings. If you do not have a blood pressure monitor at home, your local pharmacy can take a reading for you.






Smoking Status

Please let us know what your current smoking status is. More information about smoking and how to quit can be found at: https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/

Alcohol Consumption

Please let us know your current level of alcohol consumption. More information about alcohol units and advise on drinking can be found at: https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/



Height and weight

Please use the section below to let us know your most recent height and weight measurements.


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