Update Your Patient Record

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Height & Weight

  • Smoking

    Do you currently smoke? (optional)
    If 'Yes', How many cigarettes do you smoke in a day? (optional)
    Would you like us to contact you with advice on giving up smoking? (optional)

  • Alcohol

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

  • Other Information

    Are you a carer (optional)
    Date of Birth (optional)
    For example, 15 3 1984
    IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY (optional)
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 14 October 2026
Page created: 08 October 2026