Clinical Record Update Form

Updating Your Clinical Record

Contact Details

First Name*

Surname*

Date of Birth*

Address*

Street Address City Postcode

NHS Number

Home Phone

Mobile Phone

Height & Weight

Height:

feet

Weight:

stone

Waist:

inches

Blood Pressure:

The systolic is the first number of your blood pressure reading, and the diastolic is the second number. So if your blood pressure reading is 120/80, 120 is systolic and 80 is diastolic.

Systolic

Diastolic

Resting Pulse

(beats per minute)

Smoking

Have you ever smoked?

Yes

If 'Yes', please answer the following:

Do you smoke now?

Yes

If 'Yes' how many do you smoke each day?

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?

Yes

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.

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often 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 you had been 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?

Carers

Do you look after someone, as a formal or informal carer?

Yes

If yes, please provide the following information:

Caring Details

Relationship to person you care for

Other Information

Are you allergic to any medications? (please state which ones)

What is your ethnicity?

Nationality:

What is your first language?

Do you need an interpreter?

Disclaimer

The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.

The information you provide will be processed with the sole purpose of providing you with Direct Care within the surgery and in support of Direct Care elsewhere. Our Privacy Policy provides further detail about how we process your personal information for the purposes of Direct Care.

You have the right to revoke this Consent to the terms laid here, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.