Update Clinical Details Contact DetailsStart of Column 1Name D.O.B. Day Month Year Address Street Address Address Line 2 City Postcode End of Column 1Start of Column 2NHS Number Home PhoneMobile PhoneEmail End of Column 2Height and WeightHeight and WeightStart Col 1HeightFeet1234567Inches1234567891011Or in cmBlood Pressure Resting Pulse End Col 1Start Col 2WeightStone12345678910111213141516171819202122232425+Pounds12345678910111213Or in KgEnd Col 2SmokingSmokingSmokingHave you ever smoked? Yes No Do you smoke now? Yes No If Yes, how much do you smoke each day?When did you quit? Would you like us to contact you about options available to help you quit? Yes No Section BreakNew RowAlcohol1 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 often do you have a drink containing alcohol?NeverMonthlyOnce a Week2 - 3 times a week4+ times a weekHow many units of alcohol do you drink on a typical day when you are drinking?1 or 23 or 45 or 67 or 89 or moreHow often have you had (if female) 6 or more units, or (if male) 8 or more, on a single occasion in the past year?NeverLess than monthlyMonthlyWeeklyDailyOther informationDo you care for someone? Yes No If yes, please provide the following information: Caring detailsPermission date Relationship What is your ethnicity?AsianBlackMixedWhiteCountry?BritishIrishOtherWhat is your first language?
