Update your clinical record – Old Mill Surgery

Help us keep your clinical record up to date. Please complete the form as fully as possible.

Contact details
Name
First Last
Date of Birth*
Address*
House/Flat name or number Address 2 City/Town County Postcode
Phone
Mobile Phone
Email
Enter Email Confirm Email
Height & weight etc.
Height
Height in feet and inches or cms
Weight
Weight in stones and pounds or in Kg
Waist
Waist in inches or cms
Blood pressure
Systolic Diastolic
Resting pulse (beats per minute)
Smoking
Have you ever smoked?
- Yes
- No
Do you smoke now?
- Yes
- No
If '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?
- Yes
- No
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?
How often during 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
- No
Caring details
Caring permission date
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?
Other ethnicity
What is your first language?

Contact details

Height & weight etc.

Smoking

Alcohol

Other information