Update your Clinical Record Thank you for agreeing to help us keep our records current and accurate. Contact DetailsNameDate of Birth DD slash MM slash YYYY Address (including postcode)NHS Number OptionalHome Phone Number OptionalMobile Phone Number OptionalEmail Address Optional Height & Weight etc.Height OptionalFeet/inches or centimetres Weight OptionalStone/lb OR kgWaist OptionalInches OR centimetresBlood Pressure Optional(Systolic)Blood Pressure Optional(Diastolic)SmokingHave you ever smoked? Yes Optional No Optional Do you smoke now? Yes Optional No Optional How many do you smoke each day? OptionalWhen did you quit? OptionalThere are plenty of options available to help you quit. Is this something you would like us to contact you about? Yes Optional No Optional Alcohol1 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.Do you identify as: Male Optional Female Optional How often you have EIGHT or more drinks on one occasion? OptionalNeverLess than monthlyMonthlyWeeklyDailyHow often you have SIX or more drinks on one occasion? OptionalNeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking? OptionalNeverLess than monthlyMonthlyWeeklyDailyHow often during the last year have you failed to do what was normally expected of you because of drinking? OptionalNeverLess 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? OptionalNoYes, on occasionYes, more than onceOther InformationDo you look after someone? Yes Optional No Optional If yes, please provide the following informationCaring DetailsPermission DateRelationship Add RemoveAre you allergic to any mediation? (please state which ones) OptionalWhat is your ethnicity? OptionalAsianBlackMixedWhiteWhat is your nationality? OptionalBritishIrishOtherWhat is your first language? Optional
