Clinical Details Form

Contact details

Name*

Address

Postcode

Date of birth

NHS number

Home phone

Mobile phone

Height & Weight etc

Height

cm OR feet inches

Weight

kg OR Stone lb

Waist

cm OR inches

Blood pressure

systolic / diastolic

Resting pulse

Smoking

Have you ever smoked? Yes No

If yes, do you smoke now? Yes No

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 of 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?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the past year?

Other information

Are you a carer for someone? Yes No

If yes please provide the following information:

Person cared for

Permission date

Relationship

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

What is your ethnicity?

What is your first language?

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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.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

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About This Form

Personal Information