Update Your Patient Record

Your Details

Are you submitting this on someone else's behalf? If yes please provide your name, DOB and relationship to the patient.

Name *

Date of Birth *

Primary Phone Number *

Any other phone numbers you would like us to contact you on?

Email Address *

Address *

Are you happy for us to contact you via TEXT? (this may be for anything between appointment reminders or messages from the doctors) *

Yes No

Are you happy for us to contact you via EMAIL? (This will generally only be used if we do not have a mobile number for you for the GP's or Admin department to contact you about non urgent things) *

Yes No

Height & Weight

Height *

Weight *

Waist

Blood Pressure

Resting Pulse (beats per minute)

Alcohol

1 drink = 1/2 pint of beer 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.

Smoking

Do you currently/have you previously smoked? *

Yes

Used to smoke

Never smoked

If 'Yes/Used to smoke', What did you smoke?

Pipe Smoker

Cigar Smoker

Cigarette Smoker

Rolls Own Cigarettes

If 'Yes/Used to smoke', how many did you smoke per day?

Would you like us to contact you with advice on giving up smoking?

Yes No

Other Information

Are you a carer

Yes No

If 'Yes', Name of Person caring for

Their date of Birth?

WHAT IS YOUR RELATIONSHIP TO THE PERSON YOU CARE FOR?

IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY

Yes No

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. 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. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

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Update Your Patient Record

Update Your Patient Record

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