Update your basic health information

Only complete this form if you are registered with the Practice.

Your personal information provided will be solely used to update your medical records. It will not be passed to any third party, without your consent, unless required by law. This conforms to the Data Protection Act of 1998.

For further information regarding general lifestyle advice please visit NHS Health Choices.

Thank you for agreeing to help us keep your medical records up to date.

Your details Your full name

Your address

Your postcode

Date of birth (dd/mm/yyyy)

Email address

Telephone number

Your height and weight Your height in feet and inches or centimetres

Your weight in stones and pounds or kilograms

Your smoking status

Do you smoke? Yes No

If yes how many per day?

Alcohol consumption

Do you drink alcohol? Yes No

If yes how many units per week?

(1 unit = 25ml measure of spirit or 1 glass of wine or 1 half pint of beer/cider/lager)

Allergies

Do you have any allergies? Yes No

If yes please list allergies?

Your ethnic group Describe your ethnic group or background

For carers If you are a carer please name the person you care for

How long have you been a carer?

What is your relationship to the person you care for?

Terms and conditions

The internet is not secure and the transmission of data to change health information is enirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above.

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GENERAL INFORMATION

Update your basic health information

Radnor Street Surgery