Update Your Clinical Record Online

Please complete the form below to update your clinical record.

Update Clinical Records
Title
Address *
Address
Post Code
City
Country

Height and Weight

(In Feet & Inches OR cm)
(In stone & lbs OR kg)
(In Inches OR cm)

Blood Pressure

(Beats Per Minute)

Smoking

Have you ever smoked tobacco?
If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Alcohol

(1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)

Depression

Could you be depressed ?

Please answer the following questions:

Have you found little pleasure or interest in doing things?
Have you found yourself feeling down, depressed or hopeless?
Have you had trouble falling or staying asleep, or sleeping too much?
Have you been feeling tired or had little energy?
Have you had a poor appetite or been overeating?
Have you felt that you’re a failure or let yourself or your family down?
Have you had some trouble concentrating on things like reading the paper or watching TV?
Have you been moving or speaking slowly, or very fidgety, so that other people could notice?
Have you thought that you’d be better off dead or hurting yourself in some way?

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?

Other Information

(please state which ones)