Update Clinical Record Contact DetailsName D.O.B. Day Month Year Address Street Address Address Line 2 City Postcode NHS Number Home PhoneMobile PhoneEmail Height & Weight etcHeightFeet1234567Inches01234567891011Or in cmBlood Pressure Resting Pulse WeightStone12345678910111213141516171819202122232425+Pounds12345678910111213Or in KgSmokingHave you ever smoked? Yes No Do you smoke now? Yes No If Yes, how much do you smoke each day?When did you quit? Would you like us to contact you about options available to help you quit? Yes No Alcohol1 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.How often do you have a drink containing alcohol?NeverMonthlyOnce a Week2 - 3 times a week4+ times a weekHow many units of alcohol do you drink on a typical day when you are drinking?1 or 23 or 45 or 67 or 89 or moreHow often have you had (if female) 6 or more units, or (if male) 8 or more, on a single occasion in the past year?NeverLess than monthlyMonthlyWeeklyDailyOther informationDo you care for someone? Yes No If yes, please provide the following information: Caring detailsPermission date Relationship What is your ethnicity?AsianBlackMixedWhiteCountry?BritishIrishOtherWhat is your first language?
