Clinical Record Update – Lifestyle Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your Details – Step 1 of 4This form is ONLY for updating us on your lifestyle and key health information, including: blood pressure weight smoking alcohol consumption caring responsibilities It is only for patients who are registered with our practice. For updates to your name, address, mobile number etc, please complete our update your details form. Your details Please complete the following information so we can find your record in our system: Full name *FirstMiddleLastDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home address, as in our system *Address Line 1Address Line 2CityState / Province / RegionPostal CodeCHI number (if known)This number can be found on repeat prescription slips and hospital lettersNextWhich of the following are you providing today? (Select all that apply) *Height and weight dataBlood pressure readingsSmoking historyInformation about caring for someoneAlcohol consumptionHeight – please choose your preferred units: *CentimetresFeet and inchesWeight – please choose your preferred units: *KilogramsStone and poundsPreviousNextHeight and WeightPlease provide the following information: Height (cm) *cmHeight in Feet *ftand inches *inchesWeight (kg) *kgWeight in stone *stoneand pounds *poundsWaist measurement (if available) – inchesinchesWaist measurement (if available) – cmcmBMI (if known)If you know your current BMI, please enter it here.Blood Pressure Please provide a minimum of one day of blood pressure readings, up to a maximum of seven days. Use the +Add button to add extra days as required. Take readings in the morning and in the evening of each day. DateHeart rate morningSystolic morningDiastolic morningHeart rate eveningSystolic eveningDiastolic evening Add Remove pounds how prefer Is there anything else about your blood pressure readings you would like to tell us?Smoking HistoryWhat is your current smoking status?Never smokedCurrent smokerEx-smokerPlease select the option that best describes youWhen did you stop smoking?DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Select a date near to your stop date if you can’t rememberIf current or ex-smoker – average number of tobacco products smoked per dayIf you are a current or ex-smoker, please enter the approximate number you smoked per day.If current or ex-smoker – number of years smokedIf you are a current or ex-smoker, please enter approximately how many years you have smoked in total.Smoking cessation informationPlease tick if you would like us to contact you about help to stop smokingAlcohol QuestionnairePlease answer the following questions about alcohol and you. Note: 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. How often do you have a drink that contains alcohol?NeverMonthly or less2-4 times per month2-3 times per week4+ times per weekHow often during the last year have you found that you were not able to stop drinking once you had started?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you failed to do what was normally expected from you because of your drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you had a feeling of guilt or remorse after drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?NoYes, but not in the last yearYes, during the last yearCarer RegistrationAre you looking after or providing support for a relative, friend or neighbour? Your GP needs to know so you can be offered the right information, support and access to services, including vaccinations. Please select any that apply:I am the main carer for a person who would be at risk if I were to fall illI receive Carer’s AllowanceI am happy for a member of the GP practice team to ask me about this person, and the care I provide if needed.Is the person you care for a patient at this practice?YesNoIf you have their permission, please provide their nameFirstLastPlease provide further information about your caring role, if you wish to do soPreviousNextOther InformationAre there any other lifestyle or clinical updates you would like to make us aware of?If we have any queries about your updates, how would you prefer to be contacted? *Email (preferred)TelephoneLetter to home addressEmail address *EmailConfirm EmailTelephone number *GDPR Agreement *I consent to having this website store my submitted information so the practice can respond to my inquiry.This form collects your name, date of birth, address, other personal information, including health data. 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.Submit
