Health Check for Patients with Learning Difficulties

Please fill in our Health Check for Patients with Learning Difficulties if you have been asked by a clinician to do so.

Health Check for Patients with Learning Difficulties

Health Check for Patients with Learning Difficulties

Patient's Details

Please use this date format: DD/MM/YYYY.
This can be the carer's or patient's - it will be how we contact you.
In cm.
In kg.

Carer's Details

Do you have a carer?
If carer is unpaid, are they on the carer's register?

Health Check Questionnaire:

Medication and History

Do you take tablets/medicines?
Do you think you suffer from any side effects?
Do you have any problems taking your medication?
Have you had a hepatitis B injection?
Have you had a flu injection?
Are you aware of any family history of cancer?

General Health

Do you feel generally well?
Lots of headaches?
Lots of chest infections?
Itching anywhere on the body?
Lots of urine infections?
Do you have any allergies?
Do you have asthma?
Do you have epilepsy?
Do you have diabetes?
Any problems with bladder or bowel control?

Healthy Living

Do you enjoy your meals?
Do you smoke?
Does anyone in your house smoke?
Do you have trouble with your teeth?

Please make an appointment with your dentist.

Do you have any trouble with your sight?
Do you sometimes have trouble with your ears?
Are you often short of breath?
Do you exercise?

Sexual Health

Are you sexually active?
Do you understand about pregnancy?
Do you use condoms?
Do you use any form of contraception?

Women's Health

Are you a woman/female?
Have you ever had a smear test?
Have you ever had a mammogram?
(Breast Screening)
Do you have any concerns about your periods?

Mental Wellbeing

Do you sleep all night?
Do you sometimes worry?
Do you sometimes feel cross or worked up?
When you are upset, do you ever feel that you can’t breathe?
Has there been a change in your ability to remember things?
Have you ever thought of harming yourself?

Further Comments