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My physical
health.
p h ys ic a l h e a lt h ch e ck fo r p e o p le
A
using mental health services.
 Physical Health Check (PHC)

This PHC is designed to help people affected by mental illness identify (in conjunction
with a health professional) any physical health needs they might have. The Action Plan at
the end of the PHC offers the opportunity to address any identified needs. All information
on this form will be treated as CONFIDENTIAL. One copy should be filed with the
person’s notes and a further copy should be provided for them to keep.

This PHC has been updated by Rethink Mental Illness in response to the 2014/15
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national CQUIN (Commissioning for Quality and Innovation) to improve physical health
outcomes for people affected by mental illness.

Name:_______________________________________________________________________

Date of birth:__________________________________________________________________

Date of completion:____________________________________________________________

Name of assessor:_____________________________________________________________

Job role:_____________________________________________________________________

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The PHC was originally developed by Dr Michael Phelan, Linda Stradins, Dipti Amin, Anne Doyle, Rik Inglis (West London
Mental Health Trust), Rachel Isadore (Hammersmith and Fulham Social Services) and Christine Hitrov (Central and North West
London Mental Health Trust).
Physical Health Check Tool, © Rethink Mental Illness 2014
General health and lifestyle
As you go through these questions, please add anything that needs follow up to the ‘Action Plan’ on the last
page

1.1 Do you have any diagnosed physical health conditions?

If yes, please give details: (include both minor and serious conditions)

If yes, are you receiving treatment for these? Yes No

If yes, please give details:

List any conditions not currently receiving treatment:

1.2 Do you have a disability or impairment? Yes No

If yes, please give details:

1.3 Have any of your immediate family or deceased relatives (parents, siblings)
had any of the following conditions? (It is usual to specify under the age of 60 years)
Heart disease Stroke Cancer Diabetes
Family history of any other illness / condition, please specify and give details:

1.4 Please list all medications you are currently using.
(Include psychiatric and non-psychiatric medications, creams, inhalers, complementary treatments and any other
remedies)
If you do not know the names of your medication, indicate this in the table below.
Name of medication Dose Frequency Date commenced
1

Do you have any problems with any of these medications (e.g. weight gain, disrupted sleep)? Yes No
If yes, please give details:

Do you need information about any of the medications you are currently taking? Yes No
If yes, please give details:

Physical Health Check Tool, © Rethink Mental Illness 2014

1.5 Do you think you eat a healthy diet? Yes No
(prompts: regular meals, fruit and vegetables, number of takeaways)
Can you give examples of what you eat on a typical day?

1.6 Do you take part in any physical activity or exercise? Yes No

(prompts: walking, cycling, gardening etc.)
If yes, what do you do and how often?

1.7 Do you smoke cigarettes or tobacco? Yes No

If yes, how much do you smoke per day?

If no, have you smoked in the past? Yes No

If yes, what date did you quit? Yes No

1.8 Do you drink alcohol? Yes No

If yes, how often have you had 6 or more units (female), or 8 or more (male), on a single occasion in the last year?
0 1 2 3 4
Never Less than monthly Monthly Weekly Daily or almost daily

NB – one unit is half a pint of beer/lager/cider, a small glass of wine, one measure of spirits.

Are you aware of the recommended maximum units of alcohol per day? Yes No

If no, would you like more information on this? Yes No

1.9 Do you use recreational or non-prescription drugs (e.g. cannabis)? Yes No

If yes, what do you use and how often do you use them?

1.10 Would you like information and support on any of the issues raised above:
- Improving your diet Yes No
- Increasing physical activity Yes No
- Stopping or cutting down smoking Yes No
- Reducing alcohol intake Yes No
- Stopping or reducing drug use Yes No

1.11 Are you aware of the risks of sexually transmitted infection? Yes No
If no, would you like more information on this? Yes No

Would you like further information on any other sexual health issue?
(prompts: pregnancy, contraception, impotence etc.)

Physical Health Check Tool, © Rethink Mental Illness 2014

Symptoms checklist
This section is for you to describe any current physical symptoms you are experiencing. Please give as much detail as
possible in this section.

2.1 In Table A below, tick any of these symptoms experienced.

tick
Increased thirst
Problems with urination
Breathlessness
Weight gain (unexpected)
Weight loss (unexpected)
Fits / blackouts
Constipation
Difficulties having sex
Chest pain
Difficulty sleeping
Loss of feeling in feet

Please give details:

2.2 On each body figure please use numbers to indicate any areas where you experience current
or regular pain, discomfort or difficulties in your body.
Please include issues such as skin, dental, feet, ear problems or incontinence.

Place a number in each area of difficulty on the body and then use Table B to explain further details about it. For
example, ‘1’ placed over the chest area might indicate: Problem - chest pain, Frequency - when exercising, Impact
- prevents me from exercising.

Table B
For other symptoms marked on body outline, note frequency and severity in the table below:
Number Problem Frequency Impact
Example: 1 Chest pain When exercising Prevents me from exercising

Physical Health Check Tool, © Rethink Mental Illness 2014

Screening checks
This section should be used to highlight areas that may require investigation and alert you to the need for checks that may be
overdue.

3.1 Are you registered with a GP? Yes No

3.2 Are you registered with a dentist? Yes No

3.2 General health checks

Date / timing Any other details:e.g. reason for visit / results of test

When did you last visit your GP or

practice nurse?
When did you last visit your dentist?

When did you last have your eyes

tested?
When did you last have a blood test?

When did you last have a screening for

bowel cancer? (aged 60+)
When did you last have a chlamydia
screening? (25 and under)

3.3 Gender specific checks

A: Checks for women
Date /timing Any other details:
When did you last have a cervical
smear test?
When did you last have a period?

How often do you have your period?

When did you last have a mammogram

(for women aged 50+)?

Do you check your breasts for lumps or other changes? Yes No

If no, would you like more information on this? Yes No

B: Checks for men

Date /timing Any other details:
How often do you examine your
testicles?

Are you aware of the increased risk of prostate problems in men aged 50+ ? Yes No
If no, would you like more information on this? Yes No

3.4 Please record the following information if possible:

Weight (Kg) Waist Pulse Blood
circumference (cm) Pressure
Blood glucose Lipids BMI

3.5 Any other issues

Yes No
Are there any other issues we have not covered that you are concerned about?
If yes please give details:

Physical Health Check Tool, © Rethink Mental Illness 2014

Your action plan
In this table indicate any health needs that have been identified and what actions are to be taken.

Name Today’s date

Health need What action is to By whom? When is the action Followed up when Any other
identified be taken? to be taken? and by who? comments

Final questions
Are you satisfied with what we have agreed? Yes No
If no, please give details:

Is there anything you are worried about as a result of this questionnaire? Yes No
If yes, please give details:

Do you need any extra support at this time to help you with the next step(s) we have identified? Yes No
If yes, please give details:

Physical Health Check Tool, © Rethink Mental Illness 2014

Notes

Physical Health Check Tool, © Rethink Mental Illness 2014

Leading the way to a better
quality of life for everyone
affected by severe mental illness.

For further information

Telephone 0300 5000 927
Email [email protected]

www.rethink.org

Registered in England Number 1227970. Registered Charity Number 271028. Registered Office 89 Albert Embankment, London,
SE1 7TP. Rethink Mental Illness is the operating name of the National Schizophrenia Fellowship, a company limited by guarantee.
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