NCL Learning Disabilities Pre-health Check Questionnaire Annual Health Check Pre-check Questionnaire (PDF) Online Annual Health Check Pre-check Questionnaire Name First Last Known as OptionalDate of birth Day Month Year Contact NumberIs it okay to share information about you with other health professionals? Yes No Did anyone help you with this form? Yes No Your first languageDo you have any communication difficulties? Yes No I communicate by Talking Signing Using a communication aid Pointing Using gestures Other If you ticked Other, please give details below.I can understand information if it is… Written words With pictures Spoken Interpreted by a carer Other If you ticked Other, please give details below.Next of Kin's Name First Last Main Carer's Name First Last I live withDo you see anyone from CLDS, or another learning disabilities service? Yes No Do you have a health action plan? Yes No Do you have a hospital passport? Yes No If you do have a health action plan or a hospital passport, please bring these to your annual health check appointment.Do you have any allergies? Yes No If you ticked Yes, please list your allergies here.Do you have any problems taking your medication? Yes No Do you take any over-the-counter medication? Yes No Do you have any medical fears or phobias, e.g. blood tests, blood pressure tests, injections? Yes No Do you have any problems with your teeth or mouth? Yes No When did you last see a dentist?Do you have any problems with your vision? Yes No When did you last see an optician?Do you have any hearing difficulty? Yes No Do you wear a hearing aid? Yes No Have you had your hearing checked? Yes No Do you have any problems with your feet? Yes No Do you see a podiatrist? Yes No Do you have any problems with your mobility? Yes No Do you use any mobility aids, like a wheelchair, walking frame or stick? Yes No Do you see a physiotherapist or occupational therapist (OT)? Yes No Do you have any problems with eating and drinking? Yes No Do you see a dietician? Yes No Do you have any problems with swallowing? Yes No Do you see a speech and language therapist? Yes No Do you have any heartburn or indigestion? Yes No Do you have any problems going for a poo, e.g. constipation, diarrhoea or incontinence? Yes No Do you have any problems going for a wee, e.g. pain, blood or incontinence? Yes No Do you have epilepsy? Yes No If you ticked Yes, how many seizures have you had in the past month?For men and women aged 50 to 74Have you been sent a kit to test for bowel cancer? Yes Optional No Optional When did you last do the test? OptionalFor men and women aged 55 to 74 (who smoke or have smoked)Have you had lung cancer screening? Yes Optional No Optional When was your phone questionnaire? OptionalIf invited, when was your CT scan? OptionalFor menHave you had any pain or swelling in your testicles? Yes Optional No Optional For womenHave you noticed any pain or lumps in your breasts? Yes Optional No Optional If you are over 50, when did you last go for breast screening? OptionalDo you have regular periods? Yes Optional No Optional Any problems with your periods, e.g. are they heavy, painful or irregular? Yes Optional No Optional Do you have any vaginal discharge that is smelly or makes you sore? Yes Optional No Optional For women aged 25 to 64Have you had a cervical smear test? Yes Optional No Optional When was your last smear test?For everyoneWould you like advice about safe sex and contraception? Yes No Would you like advice about healthy eating? Yes No When did you last have a flu jab?Do you drink alcohol? Yes No How much alcohol do you drink?Do you take any recreational drugs? Yes No Do you smoke? Yes No If you ticked Yes, how much do you smoke?How are you feeling?Is there anything that you’re worried about?Please use this space to tell us anything else you’d like us to know Optional
