Updating Your Clinical Record

It is very important that we keep your Clinical Record up to date as this is used by our clinicians when making clinical decisions about your care and treatment. Please complete this form and we will update your records accordingly.

Last Updated: 19/10/2023

Your Details

Name *

Address and Postcode *

NHS Number

Date of Birth *

Phone Number - Mobile and/or Home *

Email Address *

Height & Weight

Height

Weight

Waist

Blood Pressure

Resting Pulse (beats per minute)

Smoking

Please indicate your current smoking status

Current Smoker

Ex - Smoker

Never Smoked

Use of e-cigarettes ONLY

If current smoker - how many cigarettes do you smoke per day?

There are plenty of options available to help you quit smoking. Would you like us to contact you with advice?

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

Do you look after someone?

Yes No

If 'Yes', please provide Caring Details

Permission Date

What is your relationship to the person being cared for?

Are you allergic to any medications? (please state which ones)

What is your ethnicity?

White

Black

Asian

Mixed

What is your first language?

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. *

I consent to the practice collecting and storing my data from this form.

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Updating Your Clinical Record

Further Information