Updating Your Clinical Record Name(Required) First Last Address Street Address Address Line 2 City Post code Date of Birth(Required) Month Day Year NHS NumberHome PhoneMobile PhoneEmail Height & Weight etcHeightPlease state centimetres or feet and inches WeightPlease state kilograms or stone and pounds Blood pressurePlease write as systolic/diastolic Resting PulsePlease write as beats per minute SmokingHave you ever smoked? Yes No Do you smoke now? Yes No How many do you smoke each day?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 Alcohol1 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?NeverLess than MonthlyMonthlyWeeklyDailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?NeverLess than MonthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking?NeverLess than MonthlyMonthlyWeeklyDailyIn 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 occassion Yes, more than once Other InformationDo you look after someone? No Yes Please provide their caring details Please provide their permission date Month Day Year What is your relationship to them? Are you allergic to any medications?Please state which onesWhat is your ethnicity?AsianBlackMixedWhiteWhat is your Nationality?BritishIrishOtherWhat is your first language? NameThis field is for validation purposes and should be left unchanged.
