Contact Details

    Date of Birth:
    NHS Number:
    Home Phone:
    Mobile Phone:

    Height & Weight etc

    Blood Pressure
    Resting Pulse


    Have you ever smoked?

    If 'Yes', please answer the following:

    Do you smoke now?

    If 'Yes' how many do you smoke each day?
    If 'No' when did you quit?
    There are plenty of options available to help you quit. Is this something you would like us to contact you about?


    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.

    MEN: How often do you have EIGHT or more drinks on one occasion?

    WOMEN: How often do you have SIX or more drinks on one occasion?

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

    How often during the last year have you failed to do what was normally expected of you because of drinking?

    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?

    Other Information

    Do you look after someone?

    If yes, please provide the following information:

    Caring Details:
    Permission Date:
    Are you allergic to any medications? (please state which ones)
    What is your ethnicity?
    What is your first language?