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Longford Primary Care Centre - Dr Haider & Partners
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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





Are You



Do you have a health action plan?

Do you have a job?

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

How do you communicate? Select as many as you wish



Tell us the names of all the people who look after you:

Do you care for anyone? This could be children, parents or partner.

Do you have any other health conditions?

Do you have any allergies?

Do you have any fears or phobias?


Do you drink alcohol?

Do you smoke?

Do you take any drugs such as cannabis, cocaine etc?

Do you take any tablets that are not from a healthcare worker (e.g. doctor or nurse) such as painkillers, vitamins etc

Do you have sex?

Do you have any problems sleeping?

Do you have any problems eating or drinking?

Do you have any problems swallowing?

Do you have constipation or diarrhoea?

Do you have any problems when you wee or poo?

Have your moods changed (e.g. are you more angry, or sad, or worried)?

Do you have sometimes get a pain in your chest?

Do you have any problems breathing?

Is there a family history of any medical illnesses, problems or learning disabilities?

Do you have any problems with any of the following:

Do you have any problems with your eyes / seeing things?

Do you have any problems with hearing?

Do you have any problems with your teeth and mouth?

Do you have any problems with your feet?

Do you have any problems with your hair, skin or nails?

Do you see any of the following health professionals?

Do you see an optician (eyes)?

Do you see an audiologist (hearing)?

Do you see a dentist (mouth and teeth)?

Do you see a podiatrist / chiropodist (feet)?

Do you see a physiotherapist?

Do you see an occupational therapist?

Do you see a psychologist / psychiatrist?

Do you see a speech therapist?

Do you see a dietician?

Other Health Questions

Do you exercise?

For men and women aged 60-69

If you are aged 60 to 69, have you received a kit to test for bowel cancer?

For men (all ages)

Have you had any pain or swelling in your testicles?

For women (all ages)

Do you have periods?
Are there any problems with your periods?
Are your periods?

Select as many as needed

Do you get any vaginal discharge that makes you feel sore or is smelly?

Have you had any pain or lumps in your breasts?
If you are over 50 years old, have you had a breast screening test?

If you are between 25 and 64 years old, have you had a cervical smear test?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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Longford Primary Care Centre - Dr Princewill & Partners

Longford Road, Longford, Coventry, West Midlands, CV6 6DR

  • 0333 332 3888
  • LPCC.BGHC@NHS.NET

Bell Green Health Centre

Roseberry Avenue, Bell Green, Coventry, West Midlands, CV2 1NE

  • 024 7668 9310
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