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The Medlock Medical Practice
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General Health Questionaire

General Health Questionaire
1. General Health
Do you have any difficulty managing your medications or understanding your prescription instructions?
3. How often do you engage in physical activity or exercise?
Have you ever noticed and changes in your mobility, such as difficulty walking or getting around?
Have you had any falls in the past year?
4. Over the past two weeks have you felt down, depressed or hopeless?
Do you feel anxious or stressed on a regular basis?
Do you have trouble sleeping or suffer from insomnia?
5. Have you experienced any changes in your weight within the last year?
Do you have any difficulties with chewing, swallowing or digesting food?
6. Have you noticed any changes in your hearing or vision within the last year?
Do you use glasses, hearing aids or other assistive devices for vision or hearing?
7. Do you live alone or with others?
8. Are you able to perform daily activities like bathing, dressing and eating on your own?
Do you need help with household chores or managing your finances?
Are you up to date with cancer screenings ( e.g. breast, colon or prostate)?
10. Do you currently smoke or use any tobacco products?
How often do you consume alcohol?
Does this pain limit you ability to carry out daily activities?
13. In the past year, have you consulted any other healthcare providers (e.g. specialists, urgent care, out of hours)?
14. Do you feel you can contact your GP when needed ( e.g by phone, online or in person) ?

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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The Medlock Medical Practice

Keppel Building, Failsworth Health Centre, Ashton Road West, Failsworth Manchester, M35 0AD

  • 0161 357 1610
  • gmicb-old.icgmedlock@nhs.net
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