- UGP - Update Your Patient Record

Please help us to keep your clinical record up to date by completing as many of these questions as possible.

Many thanks,

Unsworth Group Practice

Last Updated: 17/01/2023

Your Details

Height & Weight

Height

Weight

Blood Pressure

Smoking

Do you currently smoke? *

Yes No

If 'Yes', How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like us to contact you with advice on giving up smoking?

Yes No

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.

Do you drink alcohol? *

Yes No

How many units of alcohol do you drink on a typical day drinking? Please see: https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator

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? *

Never

Less than monthly

Monthly

Weekly

Daily

Other Information

Are you a carer

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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- UGP - Update Your Patient Record

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