Lifestyle Survey

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The survey should only take a few minutes to complete, but please provide accurate and honest answers.

We use this survey to be able to send you targeted information that we believe could help you lead a healthier lifestyle and get more from your medicines and NHS services.

    Patient's Details

    Measurements

    Smoking

    Do you smoke?

    How many per day?

    Would you be interested in support to stop smoking?

    Drinking

    How often do you have a drink containing alcohol?

    How many units of alcohol do you have on a typical day?

    How often do you have six or more drinks on one occasion?

    Exercise

    Do you do any exercise/physical activity?

    How much exercise do you do a week?

    Eating

    Do you eat fruit and/or vegetables?

    How many portions do you eat a day?

    Mental Health

    Do you feel you have someone to talk to?

    Medical Conditions

    Do you have a medical condition that requires regular medication?

    Do you require regular medicine for this condition?