Update Your Clinical Records Please complete the online form below to update your clinical records. Update Clinical Record Title: Mr Mrs Miss Ms Dr Other Forename: * Middle Name: Surname: * Date of Birth: * Address: Address: Address: Address: Postcode Postcode City City Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Telephone: * Mobile Number: Email Address: * Repeat Email Address: * What is your first language? What’s your ethnicity? White (UK) White (Irish) White (Other) Black Caribbean Black African Black Other Bangladeshi Indian Pakistani Chinese Other 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? NeverOnce a month or less2 to 4 times a month2 to 3 times a week4 or more times a week How many standard drinks containing alcohol do you have on a typical day when drinking? 01 or 23 or 45 or 67 or 910 or more During the past year, how often have you found that you were not able to stop drinking once you had started? 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? 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? NeverLess than monthlyMonthlyWeeklyDaily or almost daily Have you or somebody else been injured as a result of your drinking? 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? NoYes, on one occasionYes, more than once Depression Could you be depressed? NoYes 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 Additional Notes: Submit