Update Your Clinical Record

Title*
MrMrsMissMsMxDrOther

Forename*

Middle Name

Surname(s)*

Date of Birth*

Address*

Post Code

City

Country
—Please choose an option—EnglandScotlandWalesNorthern Ireland

Home Telephone

Mobile Number

Email*

What is your ethnicity?
—Please choose an option—England / Welsh / Scottish / Northern Irish / British IrishIrishGypsy or Irish TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed / Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black / African / Caribbean backgroundArabAny other ethnic group

Are you allergic to any medications? (please state which ones)

Height and Weight

Height

Weight

Smoking

Have you ever smoked tobacco?
YesNo

If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Alcohol

How often do you have a drink containing alcohol?
—Please choose an option—NeverOnce a month or less2 to 4 times a month2 to 3 times a week4 or more times a week

(1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)

How many standard drinks containing alcohol do you have on a typical day when drinking?
—Please choose an option—01 or 23 or 45 or 67 or 9

During the past year, how often have you found that you were not able to stop drinking once you had started?
—Please choose an option—NeverLess than monthlyMonthlyWeeklyDaily or almost daily

During the past year, how often have you failed to do what was normally expected of you because of drinking?
—Please choose an option—NeverLess than monthlyMonthlyWeeklyDaily or almost daily

During the past year, have you been unable to remember what happened the night before because you had been drinking?
—Please choose an option—NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Have you or somebody else been injured as a result of your drinking?
—Please choose an option—NoYes, but not in the past yearYes, during the past year

Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down?
—Please choose an option—NoYes, on one occasionYes, more than once

Depression

Could you be depressed?
YesNo

Carer

A carer is someone who looks after an elderly person or someone who is disabled. We do not mean a carer of a child.

Are you a Carer?
YesNo

Additional Notes