Beechwood Medical Practice

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of notifying us of your change of address.

Updating Your Clinical Record Form

Title:
Forename(s):
Surname:
NHS Number (if known):
Date of Birth:
Address:
Home Telephone:
Email Address:
Mobile:
   
Height:
Weight:
Waist Measurement:
 
Have you ever smoked:
If 'Yes', please answer the following:
Do you smoke now?:
If 'Yes' how many do you smoke each day?:
If 'No' when did you quit?:
   
Do you drink alcohol?:
If 'yes' please answer the following questions and calculate your score:
Questions
Scoring System
Your Score
 
0
1
2
3
4
How often do you have a drink that contains alcohol?
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
How many standard alcoholic drinks do you have on a typical day when you are drinking?
1-2
3-4
5-6
7-8
10+
How often do you have 6 or more standard drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Scoring: A total of 5+ indicates hazardous or harmful drinking
Find out more about alcohol and your health by clicking here
 
Are you a carer?:
If 'yes' please provide the following information:
Caring Details:
Permission Date:
Relationship:
Are you allergic to any medications? (please state which ones):
What is your ethnicity:
What is your first language: