General Health Check Form

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

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Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Health Check

Height

Current Weight

Do you have any immediate family history (e.g. Mother, father, brother, sister) of any of the following? Please check all which apply:

Heart condition/attack Diabetes High Cholesterol Respiratory disease (e.g. COPD) Stroke

Do you have any allergies? If you do, please provide details:

Diet

How would you describe your diet?

Vegetarian

Vegan

On a low fat or weight reducing diet

Gluten free

Diabetic diet

Other, please describe below

Next of Kin

Next of kin name

Next of kin contact number

Their relationship to you

Carers

Are you a carer?

Yes

Do you have a carer?

Yes

Armed Forces

Do you currently serve in the Armed Forces?

Yes

Does your partner currently serve in the Armed Forces?

Yes

Have you served in the Armed Forces in the past?

Yes

Accessibility

Do you have a preferred method of communication?

Do you have a preferred method of contact?

Is it best for you to receive information in a specific format? If yes please provide details.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Bloomfield Surgery • 95 Bloomfield Road, Bangor, Co. Down, BT20 4XA.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.