Update Your Clinical Records Please complete the online form below to update your clinical records. Update Clinical Records Title Mr Mrs Miss Ms Mx Dr Other Forename * Middle Name Surname(s) * Date of Birth * Address * Address Address Address Post Code Post Code City City Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Home Telephone Mobile Number Email * Repeat Email * What is your ethnicity? English / Welsh / Scottish / Northern Irish / British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Are you allergic to any medications? (please state which ones) Height and Weight Height (In Feet & Inches OR cm) Weight (In stone & lbs OR kg) Smoking 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. Alcohol How often do you have a drink containing alcohol? Never Once a month or less 2 to 4 times a month 2 to 3 times a week 4 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? 0 1 or 2 3 or 4 5 or 6 7 to 9 10 or more During the past year, how often have you found that you were not able to stop drinking once you had started? Never Less than Monthly Monthly Weekly Daily or almost daily During the past year, how often have you failed to do what was normally expected of you because of drinking? Never Less than Monthly Monthly Weekly Daily or almost daily During the past year, have you been unable to remember what happened the night before because you had been drinking? Never Less than Monthly Monthly Weekly Daily or almost daily Have you or somebody else been injured as a result of your drinking? No Yes, but not in the past year Yes, during the past year Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down? No Yes, on one occasion Yes, More than once Depression Could you be depressed ? Yes No 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. Are you a Carer? Yes No Additional Notes Submit