General Practice Physical Activity Questionnaire (GPPAQ)

This form is used by your doctor to assess your level of physical activity.

Please select the practice location most relevant to this Online Form submission:

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

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Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Ashfield Road Surgery • 39 Ashfield Road, Fordhouses, Wolverhampton, WV10 6QX.

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.