Update Your Records

Please select the practice location most relevant to this Online Form submission:

Update Your Records

Name

Address

Postcode

Date of Birth

NHS Number

Home Phone

Mobile Number

HeightFeet & Inches OR cm

Weightstone/lb OR kg

Waistinches OR cm

Blood Pressure(systolic)

Blood Pressure(diastolic)

Resting Pulse(beats per minute)

Have you ever smoked?

If 'Yes', please answer the following: Do you smoke now?

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?

1 drink = 1/2 pint of beeor 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 oftern 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 of 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?

Do you look after someone?

If 'Yes', please provide the following information:

Caring Details

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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Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to
Greenside Road • 88 Greenside Road, Croydon, Surrey, CR0 3PN.

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Key Information

BBC Health News

Update Your Records

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Greenside Road

Lennard Road