Pharmacy Health Check Health Check Date Appointment Time Community Pharmacy Name Completed By Patient Details Patient name Date of Birth Postcode Which practice is the patient registered with?—Please choose an option—Haigh Hall Medical PracticeShipley Medical PracticeSunnybank and Cowgill PracticeThornton and Denholme Medical PracticeClairetestAdriantestThe Willows Medical Practice Health Check Information Height(m) Weight(kg) BMI(Kg/m2) EthnicityBritish or Mixed BritishIrishOther White BackgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed backgroundIndian or British IndianPakistani or British PakistaniBangladeshi or British BanglaseshiOther Asian BackgroundCaribbeanAfricanOther Black backgroundChineseOther - ethic category Blood Pressure Reading 1 (mmHg) Blood Pressure Reading 2 (mmHg) Blood Pressure Reading 3 (mmHg) 24-hour BP arranged by the Pharmacy? YesNo Weight Management Advice given about weight management YesNoN/A Advice about Weight YesNoN/A Health Education Weight Management YesNoN/A Patient advised to lose weight YesNo Weight Management Service Opportunity Signposted YesNoN/A Is a referral to the Weight Management Service clinically appropriate and agreed by the patient? Referral RequiredPatient DeclinedN/A Physical Activity In an average week how often do you exercise? Note: twenty minutes of vigorous walking counts as one exercise session. Never1-2 times each week3-4 times each week5-7 times each week Brief Intervention for Physical Activity Completed YesNoN/A Physical Activity Opportunity Signposted YesNoN/A Is a referral to the Physical Activity Service clinically appropriate and agreed by the patient? Referral RequiredPatient DeclinedN/A Smoking Do you smoke? Current smokerEx-smokerNever smoked Smoking Cessation Advice GivenAdvice DeclinedN/A Stop Smoking Service Opportunity Signposted YesNoN/A Is a referral to the Stop Smoking Service clinically appropriate and agreed by the patient? Referral RequiredPatient DeclinedN/A General Lifestyle Advice Given YesNoN/A Any Other Comments
