Patient Record Update

Non-urgent advice: Please Note

Please only use this form for sending us information to update your clinical record.

Medical matters and official complaints cannot be dealt with via this form.

If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

If you do wish to lodge a complaint, please email frimleyicb.practicemanager.foresthealthgroup@nhs.net.
Title
Date of Birth
Address
Email
What is your ethnicity?

Height and Weight

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

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

How often do you have a drink containing alcohol?
(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?
During the past year, how often have you found that you were not able to stop drinking once you had started?
During the past year, how often have you failed to do what was normally expected of you because of drinking?
During the past year, have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down?

Depression

Could you be depressed ?

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?