Updating your Clinical Records Complete the following form to update details on your clinical record. Update Clinical Record Title Mr Mrs Miss Ms Mx Dr Other Forename * Middle Name Surname(s) * Date of Birth * Address * Address Address Address City City State/Province State/Province Postcode Postcode Home Telephone Mobile Number Email * Repeat Email * What is your ethnicity? English / Welsh / Scottish / Northern Irish / BritishIrishGypsy or Irish TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed / Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black / African / Caribbean backgroundArabAny other ethnic group Are you allergic to any medications? (please state which ones) Have you ever smoked tobacco? Yes No If you are currently a smoker and would like to stop please contact the surgery to discuss this further. How often do you have a drink containing alcohol? Please SelectNeverOnce a month or less2 to 4 times a month2 to 3 times a week4 or more times a week ( 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits) How many standard drinks containing alcohol do you have on a typical day when drinking? Please Select01 or 23 or 45 or 67 to 910 or more During the past year, how often have you found that you were not able to stop drinking once you had started? Please SelectNeverLess than MonthlyMonthlyWeeklyDaily or almost daily During the past year, how often have you failed to do what was normally expected of you because of drinking? Please SelectNeverLess than MonthlyMonthlyWeeklyDaily or almost daily During the past year, have you been unable to remember what happened the night before because you had been drinking? Please SelectNeverLess than MonthlyMonthlyWeeklyDaily or almost daily Have you or somebody else been injured as a result of your drinking? Please SelectNoYes, but not in the past yearYes, during the past year Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down? Please SelectNoYes, on one occasionYes, More than once Are you a 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. Yes No Additional Notes Submit If you are human, leave this field blank.
