Lifestyle Survey

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Once your form has been received, our prescribing pharmacist will review it and provide you with tailored information.

The form should only take a few minutes to complete, but please ensure your answers are accurate and honest. This helps us deliver targeted advice designed to support a healthier lifestyle and help you get the most from your medicines and NHS services.

 

    Your Details

    Measurements

    About You

    Smoking

    Do you smoke?

    How many per day?

    Would you be interested in accessing free stop smoking services within your workplace (including free NRT/Champix, behavioural support, carbon dioxide monitoring and resources)?

    Drinking

    How often do you have a drink containing alcohol?

    How many units of alcohol do you have on a typical day when you are drinking (one unit = half a pint of larger or one single pub measure of spirit or one small glass of wine)?

    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 if you have a problem or are in a situation that is worrying or concerning you e.g family,friend, Doctor, colleague)?

    We are also interested to know what would help you to lead a more healthy lifestyle, please let us know your thoughts.

    Physical health

    Have you taken part in a national or local campaign in the last year to improve your health (for example: joined one of the on-site fitness classes, enrolled at a gym, walk to work month, Dry January or Stoptober)?

    Would you recommend it to others?

    Have you increased your levels of walking in the last year?

    How do you travel to work?

    Mindfulness

    Are you aware of opportunities to take part in mindfulness initiatives (For example: mindfulness study days, stress management course, breathing exercise...)?

    Have you taken part in any mindfulness opportunities?

    Can you see how mindfulness is beneficial to overall well being?

    Medical Conditions

    Do you have a long term, stable medical condition that requires regular medicine in the short to medium term?

    Do you require regular medicine in respect of that medical condition?