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Update Your Patient Record

Your Details

HEIGHT & WEIGHT

SMOKING

Do you currently smoke?
If 'Yes', How many cigarettes do you smoke in a day?
Would you like us to contact you with advice on giving up smoking?

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

Are you a carer?

CONSENT

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.