Bosch Health Check Form_Layout 1 11/10/2011 10:24 Page 1

Health Check
Job No:
Details
Name
Telephone
Date

Email
Reg No.
Vehicle
Mileage
Date of next MOT
Date of next service

Visually OK
Advisory
Needs urgent attention

Follow-up
J
A
Jy
O

F
M
A
N

M
J
S
D
Authority?

Inside the car

Report

Suggested action

Repair cost ()

y/n

Report

Suggested action

Repair cost ()

y/n

Horn
Wipers
Washers
Instruments
Brake lights
Indicators
Reverse light
Fog lights
Headlights
Under the bonnet
Brake fluid test
Battery test
Coolant test
Engine oil level
Fan belt
Check camshaft belt
Air Conditioning
Raise vehicle 1.5m
Near side

Depth mm

Outer

Middle

Inner

Pressure

Make, size, speed and condition

Repair cost ()

y/n

Outer

Middle

Inner

Pressure

Make, size, speed and condition

Repair cost ()

y/n

Outer

Middle

Inner

Pressure

Make, size, speed and condition

Repair cost ()

y/n

Repair cost ()

y/n

Front tyre
Rear tyre
Off side
Front tyre
Rear tyre
Raise vehicle 2m
Boot / tailgate
Check spare tyre
Under the vehicle

Report

Suggested action

Pads / discs
Brake hoses
Steering / suspension
Driveshafts
Front pipe
Centre silencer
Rear silencer
Lower vehicle
Technicians Notes

Please Note: This report and any repair costs shown, are the results of a visual inspection only. Further checks may be necessary to determine the full extent of any
requirements. Parts subject to wear are considered defective when the maximum amount of wear indicated by the manufacturer are reached.

Technician Signature

Date