Update your Patient Record

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.

Are you a carer

Yes No

If 'Yes', Name of Person caring for

Date of Birth

WHAT IS YOUR RELATIONSHIP TO THE PERSON BEING CARED FOR?

IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY

Yes No

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.

I confirm the information I’ve given is correct and I understand how it will be used

Oops... There was an error contacting reCAPTCHA, Please try again.

Further Information

Cookies on the Poundbury Doctors Surgery website

Update Your Patient Record

Further Information