Update Clinical Information

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Update Clinical Information

Update Your Clinical Information

Keeping your clinical records up to date is very important and ensures that we provide you with the best level of care. We know that many patients change their lifestyle over time, for instance quitting smoking or reducing their alcohol intake, and this information is important for your treatment. You can update your clinical details by filling in an submitting the contact form below. Just fill in the information that is relevant to your lifestyle.

Contact Details
Title*
First Name*
Surname*
Date of Birth*
NHS Number
Address*
Contact Number
Email Address*
Physical Details
Height (ft)
(Inches)
or
Height (cm)
Weight (stone)
Weight (lbs)
or
Weight (kg)
Waist (inch)
or
Waist (cm)
Blood Pressure (systolic)
or
Blood Pressure (diastolic)
Resting Pulse (beats per minute)
Smoking
Have you smoked in the past?
- Yes
- No
If yes, do you smoke now?
- Yes
- No
If yes, how many do you smoke a day?
If no, when did you quit?
If you are a smoker, are you interested in receiving help quitting?
- Yes
- No
Alcohol
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 health workier been concerned about your drinking or suggested you cut down?
Care Information
Do you look after someone?
- Yes
- No
If yes, please provide the following information:
Caring Details
Permission Date
Relationship
Other Information
Are you allergic to any medications? (please state which ones)
What is your ethnicity?
What is your first language?
Confirmation

Please be aware that the surgery will contact you by email or telephone to confirm all information above is correct before our records about you are altered.

We cannot guarantee that the internet is secure, and the transmission of data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. If you do not wish to use the online form, please feel free to contact the practice directly on 01253 957 666.
*
- I accept the terms and conditions above

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Update Clinical Information

Update Your Clinical Information

Contact Details

Physical Details

Smoking

Alcohol

Care Information

Other Information

Confirmation

Missed Appointments

Order Prescriptions

Manage Your Health

Address

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