Update your Patient Record Title(Required) Mr Mrs Miss Ms Mx Dr Other First Names(Required) Surname(Required) Date of Birth(Required) Day Month Year Address(Required) Street Address Address Line 2 City Postcode Home Phone NumberMobile Phone NumberEmail Enter Email Confirm Email What is your ethnicity? English / Welsh / Scottish / Northern Irish / British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Are you allergic to any medications? (please state which ones) Height and WeightHeight (In Feet & Inches OR cm)Weight (In stone & lbs OR kg)SmokingHave you ever smoked tobacco? Yes No If you are currently a smoker and would like to stop please contact the surgery to discuss this further.AlcoholHow often do you have a drink containing alcohol? Never Once a month or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week (1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)How many standard drinks containing alcohol do you have on a typical day when drinking? 0 1 or 2 3 or 4 5 or 6 7 to 9 10 or more During the past year, how often have you found that you were not able to stop drinking once you had started? Never Less than Monthly Monthly Weekly Daily or almost daily During the past year, how often have you failed to do what was normally expected of you because of drinking? Never Less than Monthly Monthly Weekly Daily or almost daily During the past year, have you been unable to remember what happened the night before because you had been drinking? Never Less than Monthly Monthly Weekly Daily or almost daily Have you or somebody else been injured as a result of your drinking? No Yes, but not in the past year Yes, during the past year Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down? No Yes, on one occasion Yes, More than once DepressionCould you be depressed ? Yes No Carer A carer is someone who looks after an elderly person or someone who is disabled. We do not mean a carer of a child.Are you a Carer? Yes No Additional Notes
