Update Your Clinical Records - Winchmore Hill Practice

Title:

Forename: *

Middle Name:

Surname: *

Date of Birth: *

Address:

Postcode

City

Country

Home Telephone: *

Mobile Number:

Email Address: *

Repeat Email Address: *

What is your first language?

What’s your ethnicity?

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

Height and Weight

Height:

Weight:

Waist Circumference:

Blood Pressure

What is your blood pressure?

Smoking

Have you ever smoked Tobacco

No

Yes

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

Alcohol

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

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day when drinking?

During the past year, how often have you found that you were not able to stop drinking once you had started?

During the past year, how often have you failed to do what was normally expected of you because of drinking?

During the past year, have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down?

Depression

Could you be depressed?

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?

No

Yes