Learning Disability – Health Check – Male

My name is Debbie, I am one of the Nurse Practitioners at Carterknowle & Dore Medical Practice.

You are due an annual check-up, where we will discuss any worries you have about your health, the medicines you take and your general health.

To help with this review I have sent you some questions below; you can take your time in looking at the questions and think about your answers.

Please fill in the questions in the questionnaire below. Please do not worry if you can’t answer all the questions.

If you have someone who helps look after you, you can ask them to help answer the questions.

Once you have completed the form we will be in touch to arrange you an appointment to go through your answers and discuss any questions you are unsure about

Tell us about you

Name(Required)

Address(Required)

Telephone Number(Required)

Email Address

Do you have a Carer or Support Worker?(Required)

Are you under the care of the Community Learning Disability Team?(Required)

What is Important to you?

Do you feel well?

Comments

Are you under the care of the Community Learning Disability Team?

Comments

Do you want to tell your Doctor or Nurse something about your body?

Comments

Men's Health

Do you check your testicles (balls) and Penis (willy)- are they painful?

Comments

Are they sore and itchy?

Comments

Can you feel any lumps?

Comments

Weight

Has your weight changed in the last few months?

Comments

What is your weight, if you know?

Comments

What is your weight, if you know?

Comments

Do you have a healthy diet?

Comments

Would you like to discuss your diet with a Nurse or Doctor?

Comments

Eyes and Ears

Do you have any problems with your eyes?

Comments

Can you see ok?

Comments

Do you go for your eyes tested regularly?

Comments

When did you last have your eyes tested?

Comments

Have you noticed any problems with your hearing?

Comments

Can you hear ok?

Comments

Are your ears itchy?

Comments

Your Teeth

Do you have a dentist?

Comments

When was your last visit to the dentist?

Comments

Do your teeth or mouth hurt?

Comments

Your Health and Body

Do you have a cough that won’t go away?

Comments

Do you cough up blood?

Comments

Is your spit a strange colour?

Comments

Are you a bit wheezy? This means you can’t breathe well. It might make a strange sound when you breathe.

Comments

Do you have any difficulty breathing during the day or night?

Comments

Do you get chest pain when you exercise?

Comments

Do you have palpitations- feeling your heart beating without touching it?

Comments

Do you have swelling to your ankles, hands or body?

Comments

Do you have dry or itchy skin?

Comments

Do you have any sores or open wounds?

Comments

Do you have any new lumps or bumps on your skin?

Comments

Any changes to the colour of your skin on your body?

Comments

Do you have any problems moving or walking around?

Comments

Do you do regular exercise?

Comments

Do you have any problems sleeping?

Comments

Your Feelings

Are you worried about your memory?

Comments

Are you feeling sad, worries or angry?

Comments

Do you feel like you can’t cope or look after yourself?

Comments

Have you told someone about how your feel?

Comments

Going to the toilet

Do you have constipation? This means hard poos or you can’t do a poo

Comments

Do you have diarrhoea?

Comments

Do you have any bleeding from your bottom?

Comments

Do you need to wee more often?

Comments

Do you ever wet the bed?

Comments

Smoking & Drinking

Do you smoke?

If you do smoke, how many cigarettes a day?

Would you like help to stop smoking or cut down?

Comments

Do you drink alcohol?

How much do you drink each week?

Would you like help to stop or cut down on drinking alcohol?

Comments

Flu Vaccination

Have you had your flu jab this year?

Comments

Any other health concerns

Any other health concerns you'd like to discuss?

This field is for validation purposes and should be left unchanged.

Learning Disability – Health Check – Male

Tell us about you

What is Important to you?

Men's Health

Weight

Eyes and Ears

Your Teeth

Your Health and Body

Your Feelings

Going to the toilet

Smoking & Drinking

Flu Vaccination

Any other health concerns

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