Greenside Group Practice

Update Your Records

1Update Your Records

Name

Address

Postcode

Date of Birth

NHS Number

Home Phone

Mobile Number

Email

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?Please Choose...NoYes

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?Please Choose...YesNo

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?Please Choose...NeverLess than MonthlyMonthlyWeeklyDaily

WOMEN: How oftern do you have SIX or more drinks on one occasion?Please Choose...NeverLess than MonthlyMonthlyWeeklyDaily

How often during the last year have you been unable to remember what happened the night before because of drinking?Please Choose...NeverLess than MonthlyMonthlyWeeklyDaily

How often during the last year have you failed to do what was normally expected of you because of drinking?Please Choose...NeverLess than MonthlyMonthlyWeeklyDaily

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?Please Choose...NeverLess than MonthlyMonthlyWeeklyDaily

Do you look after someone? Please Choose...NoYes

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?Please Choose...White:BritishIrishMixed:White & Black CaribbeanWhite & Black AfricanWhite & AsianAsian or British Asian:IndianPakistaniBangladeshiBlack or Black British:CaribbeanAfricanChinese or other Ethnic Group:ChineseAny Other (please specify)

What is your first language?

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Privacy Protection

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.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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