Update you clinical record – Evelyn Medical Centre

Update your clinical record
Name

First Name Last Name
Date of birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel:
Email
example@example.com
Height & weight
Height in feet and inches
Weight in stones and pounds
Waist in inches
Blood pressure
Systolic
Diastolic
Resting pulse (beats per minute)
Smoking
Have you ever smoked?

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

YesNo
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?

YesNo
Are you allergic to any medications? (please state which ones)
What is your ethnicity
What is your first language?
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.
Should be Empty:

Update your clinical record