Update Clinical Record

Please complete the online form below to update your clinical records.

Title

Full name

Date of Birth

Address

Postcode

Home Telephone

Mobile Telephone

What is your first language?

What is your ethnicity?

Are you allergic to any medications? Please state which ones.

Height & Weight

HeightPlease advise if provided in feet and inches or centimetres

WeightPlease advise if provided in stones and pounds or kilogrammes.

WaistPlease advise if provided in inches or centimetres

Blood Pressure

What is your blood pressure?

Smoking

Have you ever smoked tobacco?

If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Alcohol

( 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day when drinking?

During the past year, how often have you found that you were not able to stop drinking once you had started?

During the past year, how often have you failed to do what was normally expected of you because of drinking?

During the past year, have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down?

Depression

Could you be depressed?

Carer

A carer is someone who looks after an elderly person or someone who is disabled. We do not mean a carer of a child.

Are you a carer?

Other Information

Which of the following best describes you?

Any additional information.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Little Bushey Surgery • Little Bushey Surgery, California Lane, Bushey, Herts, WD23 1EZ.

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Key Information

Update Clinical Record

Privacy Protection