Pre-consultation: Executive Health Check

First name *

Last name *

Email *

Phone *

Date of birth *

Primary reason: *

Annual check-up

New health concern

Company requirement

Milestone birthday

Family history concerns

Returning to fitness

Work stress / Burnout

Current or past medical conditions? (select all that apply) *

Heart disease / Angina

High blood pressure

High cholesterol

Diabetes

Cancer (type?)

Stroke or TIA

Kidney disease

Thyroid disorder

Asthma or COPD

Depression or anxiety

None of the above

Bowel screening (if age 50+):

Up to date

Overdue

Not yet offered

Declined

Prostate screening / PSA (if male 50+):

Done - normal

Done - elevated

Not done

Declined

Breast screening (if female 40+):

Up to date

Overdue

Not yet offered

Cervical screening (if female 25-64):

Up to date

Overdue

Not yet offered

Not applicable

Smoking status: *

Never smoked

Ex-smoker (quit >1 year ago)

Ex-smoker (quit <1 year ago)

Current smoker (1-10/day)

Current smoker (>10/day)

Blood pressure (if known):

Total cholesterol or lipid levels (if known):

Exercise frequency per week: *

None

1-2 sessions

3-4 sessions

5+ sessions

Family history of early heart disease (parent/sibling <55)? *

No

Yes

Not sure

Stress level: *

Low

Moderate

High

Very high / Burnout

Sleep quality: *

Excellent

Good

Fair

Poor

Hours of sleep per night: *

In the last 2 weeks, have you felt sad, down, or hopeless? *

Not at all

Several days

More than half the days

Nearly every day

In the last 2 weeks, have you had little interest or pleasure in activities? *

Not at all

Several days

More than half the days

Nearly every day

Work hours per week: *

Diet quality: *

Excellent (mostly whole foods, balanced)

Good (mostly healthy with occasional treats)

Fair (mixed healthy and processed)

Poor (mostly processed/takeaway)

Alcohol consumption per week (units): *

Stress management practices (select all that apply):

Meditation / Mindfulness

Exercise

Yoga / Pilates

Time in nature

Hobbies / Creative pursuits

Social connection

Therapy / Counselling

None

VO2 max (Apple Watch, Garmin, etc):

Resting heart rate (bpm):

HRV (heart rate variability):

Average daily steps:

Any new or concerning symptoms? *

No

Yes

Current medications (if any):

Family history of (select all that apply):

Heart disease

Stroke

Diabetes

Cancer (specify types)

High blood pressure

High cholesterol

None

Last health check (NHS, private, company):

Any significant findings from that check?

Select all that apply: *

Full blood work (lipids, glucose, liver/kidney function)

Cardiac screening (ECG, heart rate variability)

Cancer markers

Hormone panel

Fitness assessment (VO2 max, body composition)

Comprehensive screening (all of the above)

Anything else you'd like to discuss?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

What prompts your executive health check?

Primary reason: -

Medical History

Current or past medical conditions? (select all that apply) -

Cancer Screening Status

Bowel screening (if age 50+): -

Prostate screening / PSA (if male 50+): -

Breast screening (if female 40+): -

Cervical screening (if female 25-64): -

Cardiovascular Risk

Smoking status: -

Blood pressure (if known): -

Total cholesterol or lipid levels (if known): -

Exercise frequency per week: -

Family history of early heart disease (parent/sibling <55)? -

Mental Health & Wellbeing

Stress level: -

Sleep quality: -

Hours of sleep per night: -

In the last 2 weeks, have you felt sad, down, or hopeless? -

In the last 2 weeks, have you had little interest or pleasure in activities? -

Work hours per week: -

Lifestyle

Diet quality: -

Alcohol consumption per week (units): -

Stress management practices (select all that apply): -

Wearable Data (if available)

VO2 max (Apple Watch, Garmin, etc): -

Resting heart rate (bpm): -

HRV (heart rate variability): -

Average daily steps: -

Current Health Symptoms

Any new or concerning symptoms? -

Current medications (if any): -

Family History

Family history of (select all that apply): -

Last health check (NHS, private, company): -

Any significant findings from that check? -

What investigations interest you?

Select all that apply: -

Anything else you'd like to discuss? -

Upload recent blood tests, ECG, or other health reports

Optional: PDF or image files only, max 10MB each

Click to upload files

Anything else for your doctor?