Clinical Records |
Please complete the text boxes and tick where appropriate |
Surname: |
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First Names: |
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Address: |
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Postcode: |
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Date of Birth: |
dd/mm/yyyy |
NHS Number: |
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Telephone: |
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Mobile Phone: |
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Email Address: |
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Please complete the following section as accurately as you can. |
Height: |
 FeetInches
OR
Metrescm
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Weight: |
Stonelbs
OR
Kg
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Waist: |
Inches
OR
cm
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Have you ever smoked? |
No
Yes |
If 'Yes', please answer the following: |
Do you smoke now? |
No
Yes |
If 'Yes' how many do you smoke each day? |
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If 'No' when did you quit? |
dd/mm/yyyy |
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Do You Drink Alcohol? |
No
Yes |
If 'Yes', please answer the following |
How often do you have a drink containing alcohol? |
Never
Monthly or less
2 - 4 times a month
2 - 3 times a week
4 + times a week
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How many units of alcohol (see above) do you have on a typical day when you are drinking? |
1-2
3-4
5-6
7-8
10+
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Are you a carer? |
No
Yes |
If yes, please provide the following information: |
Caring Details: |
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Permission Date: |
dd/mm/yyyy |
Relationship: |
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Are you allergic to any medications?
(please state which ones) |
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What is your Ethnicity? |
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What is your Nationality? |
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What is your first language? |
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