Lifestyle Survey

Your age (please select)...16 - 2526 - 3031 - 4041 - 5051 - 6061 - 7070 +

Your sex (please select)...MaleFemaleOther

Smoking

Do you smoke?

Please select...YesNo

Drinking

How often do you have a drink containing alcohol?

Please select...NeverMonthly or less2-4 times a month4 or more times a weekDaily

Exercise

Do you do any exercise/physical activity?

Please select...YesNo

Eating

Do you eat fruit and/or vegetables?

Please select...YesNo

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)?

Please select...YesNo

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)?

Please select...YesNo

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

Please select...YesNo

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

Please select...YesNo

Have you taken part in any mindfulness opportunities?

Please select...YesNo

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

Please select...YesNo

Your pharmacy branch
—Please choose an option—Narborough RoadCross StreetWollaton RoadNottingham RoadHartington RoadWelford RoadSpinney HillCoventryBridge Road

I consent to Vision Pharmacy running an SCR check for a summary on my care records.