Step 1 - Pre question

From this point on please answer all the questions as if you are the person you are completing the form for.

Step 2 - Personal info

Please enter your first name here. This should be the name by which you are known.
Please enter your last name here.
Please use a memorable word as this will be used to verify your details
Please re-enter your Password




Sorry it looks like you have taken an assessment . If something has changed or you feel you need to take another assessment please click here to contact one of our advisers.

You will be able to retake the assessment in days (days are based on number of days left until 12 weeks have passed since last assessment date).

Step 3 - Personal

Step 4 - Smoking

Step 5 - Social

Step 6 - Financial

Step 7 - Emotional

Step 8 - Weight

BMI Calculator

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lb
kg
ft
in
cm

Step 9 - Employment

Step 10 - Alcohol

Step 11 - Housing

 
 
 

Alcohol Audit Questions

This section is not required

Cold Homes

This section is not required

Step 12 - Equality

Step 13 - Contact info

Based on your postcode we have found these addresses
Please tell us how you would like us to keep in contact with you

Step 14 - Final