Health Check for People with a Learning Disability

Please complete this form before you see the doctor. When you come to see the doctor please being all of your medicines with you.



DD/MM/YYYY










For example, a family home, a residential care home, your own home, supported living.

Select as many as you wish





This could be children, parents or partner.




















Do you have any problems with any of the following:






Do you see any of the following health professionals?










Other Health Questions


For men and women aged 60-69


For men (all ages)


For women (all ages)

Select as many as needed




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This information is retained for up to 28 days.

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