Learning Disabilities Health Check Questionnaire

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All questions marked with a * are mandatory

We would like to invite you to your Annual Health Check

  • Step 1. Please fill in this questionnaire before your health check

If you need help to fill in your questionnaire you may like to ask a family member, a friend, your carer or support worker.

You may like to think about some of your answers before writing them down - you may like to complete the questionnaire over several days.

  • Step 2. Your GP Practice will look at your completed questionnaire, then tell you the DATE of your health check
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About Me
Gender: *
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Review

Changes we can make to help you are called Reasonable Adjustments

What changes can your GP Practice make to help you attend your health check?: *
Did someone help you to fill in this questionnaire?:
Would you like someone to attend your health check with you?:
Background
Do you have any worries about your disability since your last review?:
How do you tell someone if you are ill or in pain?:
Do you have problems with eating, drinking or swallowing?:
Can you choose what you would like to eat and drink?:
Do you have any special dietary needs or a feeding tube?:
Do you have epilepsy?:
Do you have diabetes?:
Care Team

Next of Kin

This is your closest family member or your first point of contact in an emergency

Would you like your GP Practice to share the result of your health check with the people who help to care for you?:
Support

I need help with

Bathing:
Dressing:
Help with meals:
Drinking:
Going to the toilet:
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Where I live
I live:
Are you able to move around easily where you live?:
Do you use mobility aids?:
Lifestyle and Wellbeing
Do you drink alcohol? Drinks like wine, beer, cocktails.:
Do you smoke? This includes cigarettes and e-cigarettes.:
Are you in a relationship?:
Have you had a sexual health check? :
Do you use contraception?:
Would you like information about the Social Prescribing health and wellbeing service?:
Do you attend a day centre? :
Physical Health
Do you go to the dentist?:
Do you go to the optician?:
Do you have your hearing checked?:
Do you have your feet checked?:
Do you have heart problems?:
Do you have breathing problems? :
Do you have pains in your chest or get puffed out easily?:
Do you find it hard to bend? :
Do you find it hard to hold things?:
Do you find it hard to walk? :
Do you have any unusual bruises or sores?:
Have you noticed any changes to your moles?:
Do you have problems going for a wee or poо?:
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Mental Health
Have you been feeling low, sad or depressed?:
Have you been feeling anxious or worried? :
Have you little interest or pleasure in doing things?:
Have you started to have mood swings?:
Do you have problems sleeping?:
Dementia - Do you think you have forgotten more things?:
Do you worry about your memory or feeling confused?:
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Screening (For women only)
Screening (For men only)
Do you know how to check your balls?:
For men over 50 years: Have you had prostate screening?:
For men age 65 to 74 years: Have you had AAA screening? This checks the blood vessel that runs from your heart down through your tummy.:
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Recent Vaccinations in the last 12 months
Have you had your flu vaccination?:
Have you had a vaccination for pneumonia and bronchitis?:
Have you had your covid vaccination and booster?:
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Drugs
Allergies
Do you have any allergies or sensitive to any medication? :

I take the following medication for

On repeat prescription or taken for a short time only:
On repeat prescription or taken for a short time only:
On repeat prescription or taken for a short time only:
On repeat prescription or taken for a short time only:
How do you prefer to take your medication?:
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Would you like Easy Read information about how to stay well and healthy?
The Community Learning Disability Team:
Resources developed by the Gloucestershire LeDeR programme:

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Providing NHS Services

Contact

Wallis Avenue Surgery
Wallis Avenue
Maidstone
Kent
ME15 9JJ

Telephone: 01622 686 963

The Practice

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