HomeUseful InformationUpdating Your Clinical Record Updating Your Clinical Record Please complete the form below to update your clinical record
Name Address Postcode Date of Birth Home Phone Number Mobile Number Email Address Height Feet Select01234567 Inches Select01234567891011 OR cm Weight Stone lb Select012345678910111213 OR kg Waist inches OR cm Blood Pressure Systolic Diastolic Resting Pulse (beats per minute) Smoking Have you every smoked? YesNo If Yes, please answer the following: Do you smoke now? YesNo If Yes, how many do you smoke each day? If No, when did you quit? There are plenty of options available to help you quit. Is this something you would like us to contact you about YesNo 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? SelectNeverLess than monthlyMonthlyWeeklyDaily WOMEN: How often do you have SIX or more drinks on one occasion? SelectNeverLess than monthlyMonthlyWeeklyDaily How often during the last year have you been unable to remember what happened the night before because you had been drinking? SelectNeverLess than monthlyMonthlyWeeklyDaily How often during the last year have you failed to do what was normally expected of you because of drinking? SelectNeverLess than monthlyMonthlyWeeklyDaily 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? SelectNoYes on one occastionYes more than once Other Information Do you look after someone? YesNo If yes, please provide the following information: Caring Details Permission Date Relationship Are you allergic to any medications? (please state which ones) What is your ethnicity? AsianBlackMixedWhite What is your nationality? BritishIrishOther What is your first language? Send
