Contact Details

What is your first language?
What is your ethnicity?			Asian Black Mixed White Not stated / refused    British Irish Other
Are you allergic to any medications? (please state which ones)

Height & Weight

Height	0 1 2 3 4 5 6 7  feet	0 1 2 3 4 5 6 7 8 9 10 11  in	OR	cm
Weight	stone	0 1 2 3 4 5 6 7 8 9 10 11 12 13 lb	OR	kg
Waist	inches		OR	cm

Blood Pressure

What is your blood pressure?

Smoking

Have you ever smoked tobacco?

No

Yes

Do you currently smoke?   No  Yes

If yes, how many cigarettes do you smoke a day?

If no, when did you quit smoking?

If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Alcohol

( 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)
How often do you have a drink containing alcohol?	Never Once a month or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week
How many standard drinks containing alcohol do you have on a typical day when drinking?	1 or 2 3 or 4 5 or 6 7 to 9 10 or more
During the past year, how often have you found that you were not able to stop drinking once you had started?	Never Less than Monthly Monthly Weekly Daily or almost daily
During the past year, how often have you failed to do what was normally expected of you because of drinking?	Never Less than Monthly Monthly Weekly Daily or almost daily
During the past year, have you been unable to remember what happened the night before because you had been drinking?	Never Less than Monthly Monthly Weekly Daily or almost daily
Have you or somebody else been injured as a result of your drinking?	No Yes,but not in the past year Yes, during the past year
Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down?	No Yes, on one occasion Yes, more than once

Depression

Could you be depressed ?

No Yes

Carer

A carer is someone who looks after an elderly person or someone who is disabled. We do not mean a carer of a child.

Are you a carer?

No

Yes

If yes, please provide the following information:
	Caring Details:
	Permission Date:
	Relationship:

Which of the following best describes you?

Employed (full or part time, inc. self employed)

Unemployed and looking for work

At school or in full time education

Unable to work due to long term illness

Looking after your home/family

Retired

Other

Additional Notes: