Update Your Patient Record Form Your DetailsName First Last Date of Birth Day Month Year Phone OptionalEmail Height & WeightHeight OptionalWeight OptionalWaist OptionalBlood Pressure OptionalResting Pulse (beats per minute) OptionalSmokingDo you currently smoke? Yes Optional No Optional If 'Yes', How many cigarettes do you smoke in a day? 1 to 9 Optional 10 to 19 Optional 20 to 39 Optional 40 or more Optional Would you like us to contact you with advice on giving up smoking? Yes Optional No Optional 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.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? Never Optional Less than monthly Optional Monthly Optional Weekly Optional Daily Optional How often during the last 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 Optional How often during the last year 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 Optional 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? No Optional Yes, on one occasion Optional Yes, more than once Optional Other InformationAre you a carer Yes Optional No Optional If 'Yes', Name of Person caring for OptionalWhat is your relationship to the person you are cared for? OptionalIs the person you care for registered at this surgery? Yes Optional No Optional THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. I consent to the practice collecting and storing my data from this form.