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Update Your Patient Record
Last Updated: 01/10/2019
Your Details
Name
*
Date of Birth
*
Phone Number
Email Address
*
Height & Weight
Height
Weight
Waist
Blood Pressure
Resting Pulse (beats per minute)
Smoking
Do you currently smoke?
Yes
No
If 'Yes', How many cigarettes do you smoke in a day?
1 to 9
10 to 19
20 to 39
40 or more
Would you like us to contact you with advice on giving up smoking?
Yes
No
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?
*
Never
Less than monthly
Monthly
Weekly
Daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily
How often during the last year have you failed to do what was normally expected of you because of drinking?
Never
Less than monthly
Monthly
Weekly
Daily
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?
No
Yes, on one occasion
Yes, more than once
Other Information
Are you a carer
Yes
No
If 'Yes', Name of Person caring for
Date of Birth
WHAT IS YOUR RELATIONSHIP TO THE PERSON BEING CARED FOR?
IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY
Yes
No
THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
*
I consent to the practice collecting and storing my data from this form.
Submit Form
Further Information
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