Are you allergic to any medication or do you have any other allergies? Yes No If yes please list: Please list any medication you are currently taking: Name and address of previous doctor: Are you a carer or being cared for? Yes No If yes please give details: Lifestyle Height Weight Do you smoke? Yes No If yes, how many per day? Have you ever Would you like help to Yes No Yes No smoked? stop smoking? Do you take regular exercise? If yes, how many time a week? Yes No Alcohol scoring system 0 1 2 3 4 Total 2 4 2 3 – – How often do you have a drink Monthly 4+ times Never times per times per containing alcohol? or less per week month week How many units of alcohol do you 1 2 3 4 5 6 7 8 10+ – – – – drink on a typical day? How often have you had 6 or more Less or units (female) 8 or more units (male) than Monthly Weekly almost on a single occasion in the last year? monthly daily Signed: Date:
Are you allergic to any medication or do you have any other allergies? Yes No If yes please list: Please list any medication you are currently taking: Name and address of previous doctor: Are you a carer or being cared for? Yes No If yes please give details: Lifestyle Height Weight Do you smoke? Yes No If yes, how many per day? Have you ever smoked? Yes No Would you like help to stop smoking? Yes No Do you take regular exercise? Yes No If yes, how many time a week? Alcohol scoring system 0 1 2 3 4 Total How often do you have a drink containing alcohol? Never Monthly or less 2 – 4 times per month 2 – 3 times per week 4+ times per week How many units of alcohol do you drink on a typical day? 1 – 2 3 – 4 5 – 6 7 – 8 10+ How often have you had 6 or more units (female) 8 or more units (male) on a single occasion in the last year? Less than monthly Monthly Weekly or almost daily Signed: Date:
New%20Patient%20Registration%20Form%20V2.docx