ServiceS WE OFFER Patients are now able to book Routine GP Appointments and make Repeat Prescription Requests on-line.
helpful Contact numbers For all kind of emergencies it is important for you to have the right phone number for your problems.
Requests We think its important for you to keep everything up to date that's why you can update your details online right here.
Update Clinical Records
Name
Date of Birth: NHS Number:
Home phone: Mobile Phone:
Adress:
Post code: E-mail: A value is required.
Height and weight
Height 0 1 2 3 4 5 6 7 feet 0 1 2 3 4 5 6 7 8 9 10 11 In or cm:
Weight stone 0 1 2 3 4 5 6 7 8 9 10 11 12 lb. or kg
Waist: inches
Blood Pressure: (systolic) / (diastolic)
Resting Pulse: (beats per minute
Smoking
Yes: No:
If yes please answer the following
Do you smoke now Yes: No:
If yes, how many do you smoke a day?
If no, when did you quit?
Would you like us help you stop smoking ? Yes: No:
Alcohol
( 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)
MEN: How often do you have EIGHT or more drinks on one occasion? Please choose: Never Less than monthly Monthly Weekly Daily 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? Please choose: Never Less than monthly Monthly Weekly Daily
How often during the last year have you failed to do what was normally expected of you because of drinking? Please choose: Never Less than monthly Monthly Weekly Daily
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: No Yes, one occasion Yes, more than one occasion
Other Information
Are you allergic to any medications? (please state which ones)
What is your ethnicity? Asian Black Mixed White Please choose: British Irish Other ......
What is your first Language?
Dr. Shah's Surgery.
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