Update your Patient Record

Do you currently smoke?

Yes No

If 'Yes', How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like us to contact you with advice on giving up smoking?

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.

Other Information

Are you a carer

Yes No

If 'Yes', Name of Person caring for

Date of Birth

WHAT IS YOUR RELATIONSHIP TO THE PERSON BEING CARED FOR?

IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY

Yes No

I consent to you referring me to Adult Social Care for an assessment.

Yes No

Reasonable adjustment

A service should know about a person’s need for adjustments when they are referred or present for care.

Consent

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

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Update Your Patient Record

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