Update Your Clinical Record.

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Have you ever smoked?

If yes, please answer all other questions in this section.

Yes

No

Do you smoke now?

Yes

No

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Yes

No

MEN: how often do you have eight or more drinks on one occasion? And WOMEN: how often do you have six or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

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?

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?

No

Yes, on one occasion

Yes, more than once

Do you look after someone?

Yes

No

What is your ethnicity?

White - British

White - Irish

White - Other

Asian - British

Asian - Irish

Asian - Other

Black - British

Black - Irish

Black - Other

Mixed

Other

Privacy Policy *

This form collects your name, date of birth, email, other personal information and medical details which you enter. We use Squarespace as our website provider and any information you enter into this form is also processed by them in accordance with GDPR and forwarded to Severn Valley Medical Practice's NHS email address. 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.

I consent to the practice collecting and storing my data from this form.