Help us keep your clinical record up to date Contact detailsName First Last Date of Birth*Address* House/Flat name or number Address 2 City/Town County Postcode PhoneMobile PhoneEmail Enter Email Confirm Email Height & weight etc.HeightHeight in feet and inchesor cmsWeightWeight in stones and poundsor in KgWaistWaist in inchesor cmsBlood pressureSystolicDiastolicResting pulse (beats per minute)SmokingHave you ever smoked?YesNoDo you smoke now?YesNoIf 'yes', daily how many?If 'No' when did you quit?please give month and year(mm/yyyy)There are plenty of options available to help you quit. Is this something you would like us to contact you about?YesNoAlcohol1 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?Please choose...NeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?Please choose...NeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking?Please choose...NeverLess than monthlyMonthlyWeeklyDailyIn 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?NoYes, on one occasionYes, more than onceOther informationDo you look after someone?YesNoCaring detailsCaring permission date Date Format: DD slash MM slash YYYY What is your relationship to the person you care for?Are you allergic to any medications? (please state which ones)What is your ethnicity?White: British or Mixed BritishWhite: IrishAny other White backgroundMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianAny other mixed backgroundAsian: Indian or British IndianAsian: Pakistani or British PakistaniAsian: Bangladeshi or British BangladeshiAny other Asian backgroundBlack: CaribbeanBlack: AfricanAny other Black backgroundChineseAny other ethnic group - Specify belowNot specifying Ethnic CategoryOther ethnicityWhat is your first language?
