Locate Us:
2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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GDPR Patient Leaflet PRIVACY NOTICE
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Please take a moment to fill out the following information, as it will allow us to fast track your assessment

Patient Name
Date Of Birth
Contact Number
E-Mail Address
Address

1. How Many Hours Did You Spend Exercising Last Week?

I Don't Exercise

Less Than 1 Hour

1-3 Hours

More Than 3 Hours

2. What Does Your Work Mainly Involve?

Not Working

Physical Effort

Sitting/Standing

Always Active

3. Do You Cycle?

I Do Not Cycle

Less Than 1 Hour Per Week

1-3 Hours Per Week

More Than 3 Hours Per Week

4. How Much Time Do You Spend Walking?

None

Less Than 1 Hour Per Week

1-3 Hours Per Week

More Than 3 Hours Per Week

5. How Much Time Do You Spend Doing Housework Or Childcare

None

Less Than 1 Hour Per Week

1-3 Hours Per Week

More Than 3 Hours Per Week

6. How Much Time Do You Spend Gardening Or Doing DIY

None

Less Than 1 Hour Per Week

1-3 Hours Per Week

More Than 3 Hours Per Week

7. What Do You Think Is Your Usual Walking Pace

Slow

Steady

Brisk

Fast

8. Do You Smoke?

Yes

No

9. Have You Ever Smoked?

Yes

Never

10. How Many Do You Smoke A Day? (if applicable)

N/A

Less Than 5

5-15

More Than 15

11. Would You Like More Info On Quitting?

Yes

No

12. Do You Drink Alcohol?

Yes

No

Never

13. If Yes, Do You Drink Daily?

Yes

No

Occasionally

14. Roughly How Many Units Per Day Do You Drink?

1-2 Units

3-6 Units

7 Or More Units

15. What Is Your Body Mass Index?

16. What Is Your Ethnicity?

17. Do You Have A Family History Of:

Heart Disease
Diabetes
High Blood Pressure
Kidney Disease
Stroke

18. If You Checked Any Of The Above, Please List The Family Relation:

19. If You Have A Family History Of Heart Disease/Stroke, Did It Occur At:

Less Than 65 Years Of Age

65 Years Of Age Or Greater

N/A

20. Do You Eat At Least 5 Portions Of Fruits And Vegetables Every Day?

Yes

No

21. What Is Your Salt Intake?

Low

Medium

High

22. Is Your Diet Low Or High In Fat?

Low

High

23. Do You Consider Yourself As Having Any Memory Problems?

Yes

No