Updating Your Clinical Record

Contact Details
Name:		Date of Birth:
Address		NHS Number
		Home Phone
		Mobile Phone
Postcode		Email
Height & Weight etc
Height	feet in	OR	cm
Weight:	stone lb	OR	kg
Waist:	inches	OR	cm
Blood Pressure:	(systolic) / (diastolic)
Resting Pulse:	(beats per minute)

Smoking
Have you ever smoked?		No Yes
If 'Yes', please answer the following:
Do you smoke now?		No Yes
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?		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?
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?		No Yes
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?
What is your first language?

About This Form

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

Fields marked with a red asterisk are
compulsory.

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.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.