Updating your Clinical Record Thank you for agreeing to help us keep our records current and accurate. Title Mr Mrs Miss Ms Mx Dr Other First NamesSurnameDate of Birth Day Month Year Address Street Address Address Line 2 City Postcode Home Phone Number OptionalMobile Phone Number OptionalEmail Enter Email Optional Confirm Email Optional What is your ethnicity? English / Welsh / Scottish / Northern Irish / British Optional Irish Optional Gypsy or Irish Traveller Optional Any other White background Optional White and Black Caribbean Optional White and Black African Optional White and Asian Optional Any other Mixed / Multiple ethnic background Optional Indian Optional Pakistani Optional Bangladeshi Optional Chinese Optional Any other Asian background Optional African Optional Caribbean Optional Any other Black / African / Caribbean background Optional Arab Optional Any other ethnic group Optional Are you allergic to any medications? (please state which ones) OptionalHeight and WeightHeight Optional(In Feet & Inches OR cm)Weight Optional(In stone & lbs OR kg)SmokingHave you ever smoked tobacco? Yes Optional No Optional 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 Optional Once a month or less Optional 2 to 4 times a month Optional 2 to 3 times a week Optional 4 or more times a week Optional (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 Optional 1 or 2 Optional 3 or 4 Optional 5 or 6 Optional 7 to 9 Optional 10 or more Optional During the past year, how often have you found that you were not able to stop drinking once you had started? Never Optional Less than Monthly Optional Monthly Optional Weekly Optional Daily or almost daily Optional During the past year, how often have you failed to do what was normally expected of you because of drinking? Never Optional Less than Monthly Optional Monthly Optional Weekly Optional Daily or almost daily Optional During the past year, have you been unable to remember what happened the night before because you had been drinking? Never Optional Less than Monthly Optional Monthly Optional Weekly Optional Daily or almost daily Optional Have you or somebody else been injured as a result of your drinking? No Optional Yes, but not in the past year Optional Yes, during the past year Optional Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down? No Optional Yes, on one occasion Optional Yes, More than once Optional DepressionCould you be depressed ? Yes Optional No Optional 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 Optional No Optional Additional Notes Optional
