Update your Clinical Record - Tudor Gate Surgery

If you would like to help us maintain up to date clinical records, please consider completing the following form.

Contact Details

Name

Date of Birth

Address

Postcode

NHS Number (if known)

Home Phone

Mobile Phone

Height & Weight Etc

Height (in feet or cm)

Weight (in stone or kg)

Waist (in inches or cm)

Blood Pressure ( systolic / diastolic)

Resting Pulse (beats per minute)

Smoking

Have you ever smoked?

Yes

If YES, Do you smoke now?

Yes

If YES, How many do you smoke each day?

If NO, when did you quit?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Yes

Alcohol

1 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?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

In the last year have you failed to do what was normally expected of you because of drinking?

In 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?

Other Information

Do you look after someone>

Yes

If YES, please provide the following information:

Caring Details

Permission Date

Relationship

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

What is your ethnicity and nationality?

What is your first language?

About This Form

Thank you for agreeing to help us keep our records current and accurate.

Note:

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.