Do it Online

Title

Forename *

Middle Name

Surname(s) *

Date of Birth *

Address

Post Code

City

Country

Home Telephone

Mobile Number

Email *

Repeat Email *

What is your ethnicity?

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

Height and Weight

Height

(In Feet & Inches OR cm)

Weight

(In stone & lbs OR kg)

Smoking

Have you ever smoked tobacco?

Yes

No

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?

(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?

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 ?

Yes

No

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?

Yes

No

Additional Notes

Viewing your online medical record:

Patient Access

Updating Clinical Records Form