Provide your Personal information / Health Questionnaire Update your Clinical Record Details Contact Details Full Name: Date of Birth: Home Tel: Mobile Number: Email Address: Address: Next of Kin Name: Relationship to Patient: I give permission for the named person to have limited access to my medical records if I am incapacitated I give consent for the person named to call for results Contact Me I am happy to be contacted by EMAIL relating to health issues I am happy to be contacted by TEXT relating to health issues I am happy to be contacted by TELEPHONE relating to health issue Other preferred method of contact Consent: I confirm that I consent to being contacted relating to any of my health issues as indicated above. I confirm that it is my responsibility to keep my details up to date and I will inform you of any changes. Date: Lifestyle Smoking Status Smoker Ex Smoker Never Smoked When did you quit? How much do you smoke per day? Would you like help/information about quitting? Yes No Please contact The Smoking Hub on 01183 341 852 - Clinics are held on Tuesdays and Thursdays, or ask in reception. What is your average alcohol intake? (Units per week) 1 standard glass of wine is roughly 2.2 units 1 standard pint of beer is roughly 2.8 units 1 single 40% spirit is roughly 1 unit Height Weight Electronic Prescribing Service We can now automatically send your prescriptions electronically to a pharmacy of your choice. Please select your chosen pharmacy below. Alphington Pharmacy Boots: Exe Bridge Boots: High Street Boots: Mount Pleasant Boots: St Thomas Lloyds Luxtons Sainsburys Superdrug Exwick Pharmacy Other Please state other pharmacy: Submit