Update Your Clinical Record – Fairfax Group Practice

Contact details

Name

First Last

Date of Birth*

Address*

House/Flat name or number Address 2 City/Town County Postcode

Phone

Mobile Phone

Email

Enter Email Confirm Email

Height & weight etc.

Height

Height in feet and inches	or cms

Weight

Weight in stones and pounds	or in Kg

Waist

Waist in inches	or cms

Blood pressure

Systolic	Diastolic

Resting pulse (beats per minute)

Smoking

Have you ever smoked?

Yes
No

Do you smoke now?

Yes
No

If 'yes', daily how many?

If 'No' when did you quit?

please give month and year(mm/yyyy)

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

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.

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Other information

Do you look after someone?

Yes
No

Caring details

Caring permission date

What is your relationship to the person you care for?

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

What is your ethnicity?

Other ethnicity

What is your first language?

Consent*

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

I agree to the privacy policy.