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Updating Your Clinical Record

Contact Details

Name: Required

Date of Birth: Required

Date

Address: Required

Postcode: Required

NHS Number:

Home Phone:

Mobile Phone:

Email Address:

Height and Weight etc

Height:

Weight:

Waist:

Blood Pressure:

Resting Pulse:

Smoking

Have you ever smoked?

None

Yes

If 'yes', do you smoke now?

None

Yes

If 'yes', how many do you smoke each day?

If 'no', when did you quit?

Date

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

None

Yes

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Other Information

Do you look after someone?

None

Yes

If yes, please provide the following details:

Caring Details:

Permission Date:

Relationship:

Are you allergic to any medications? (please state which ones)

What is your ethinicity?

What is your nationality?

What is your first language?

I agree to the privacy policy

About This Form

Thank you for agreeing to help us keep our records current and accurate.

Note:

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.