Update your Patient Record

Name *

ADDRESS (INCLUDING POSTCODE) *

Date of Birth *

Phone Number *

DO YOU CONSENT TO THE PRACTICE CONTACTING YOU BY TEXT *

Yes No

Email Address

Smoking

If you are a current smoker who would like to give up you can seek advice and support from your local community pharmacy or by clicking on this link to Quit Your Way Scotland information.

https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/quit-your-way-scotland/#:~:text=Getting%20help%20from%20local%20services,and%20specialist%20stop%20smoking%20services.

Do you currently smoke?

YES

EX-SMOKER

If 'Yes', How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

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.

HOW MUCH ALCOHOL DO YOU DRINK IN AN AVERAGE WEEK

Are you a carer

Yes No

If 'Yes', Name of Person caring for

Date of Birth

WHAT IS YOUR RELATIONSHIP TO THE PERSON BEING CARED FOR?

IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY

Yes No

DO YOU HAVE A CARER?

Yes No

IF YES PLEASE TELL US WHO THIS CARER IS.

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. *

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

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