138 Chapel Street, Salford M3 6AF England    0161 819 4790

138 Chapel Street, Salford M3 6AF England   
0161 819 4790



Update Clinical Record


Thank you for agreeing to help us keep our records current and accurate.

Fields marked with an asterisk are compulsory.

Note: By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.


1

Contact Details:

2

Personal Information:

3

Smoking:

Have you ever smoked?

If yes then please answer the following:

Do you smoke now?

If ‘Yes’ how many do you smoke each day?

Else 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?

4

Alcohol:

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?

5

Other Information:

Do you look after someone?

If ‘Yes’ then please provide the following information:




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