Update your clinical record Name First Name Last Name Date of birth * - Month - Day Year Date Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Tel: Email example@example.com Height & weight Height in feet and inches Weight in stones and pounds Waist in inches Blood pressure Systolic Diastolic Resting pulse (beats per minute) Smoking Have you ever smoked? Yes No There are plenty of options available to help you quit. Is this something you would like us to contact you about? 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? Please Select 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? Please Select 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? Please Select 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? Please Select No Yes, on one occasion Yes, more than once Other Information Do you look after someone? Yes No Are you allergic to any medications? (please state which ones) What is your ethnicity Please Select White: British or Mixed British White: Irish Any other White background Mixed: White and black Caribbean Mixed: White and black African Mixed: White and Asian Any other mixed background Asian: Indian or British Indian Asian: Pakistani or British Pakistani Asian: Bangladeshi or British Bangladeshi Any other Asain background Black: Caribbean Black: African Any other Black background Chinese Other ethnic group Not specify Ethnic Category What is your first language? Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website. * I agree to the privacy policy. Submit Should be Empty:
