Form

Bolton Community Practice
Updating Your Clinical Record
About This Form

Thank you for agreeing to help us keep our records current and accurate.

Fields marked with a red asterisk are compulsory.

Note:

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 to notify us of your information.
Contact Details
Name *
Date of Brith *

Day Month Year
Address *
Post Code *
NHS Number
Home Phone
Mobile Phone
E-mail
Height & Weight etc....
Height:
Feet
Inches
Centimetres
Weight:
Stone
Pound
Kilogram
Waist:
inches
Centimeters
Blood Pressure:
systolic
diastolic
resting pulse
beats per minute
Smoking
Have you ever smoked?

No Yes
If 'Yes' please answer the following
Do you smoke now?

No Yes
If 'Yes' how many do you smoke each day?
If 'No' when did you quit?
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?

No Yes
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?
Should be Empty:

Bolton Community Practice

Updating Your Clinical Record

About This Form

Contact Details

Height & Weight etc....

Height:

Weight:

Waist:

Blood Pressure:

Smoking

Alcohol

Other Information