The Accessible Information Standard aims to ensure patients, or their carers, easily receive, access and understand information. If you have any communication needs relating to a disability, impairment or sensory loss, or anything else you feel may be relevant to your needs, please let us know below. You may also ask at Reception for a form to complete, which will help you give this information. CARERS Are you a Carer? No Yes A carer is someone who looks after a relative, friend or neighbour who could not manage without their help. If you are a carer then please specify the relationship of the person you care for eg parent, child, neighbour, friend ………………………………… HEALTH PROFILE: How often do you have a drink containing alcohol? Never  Please tick the reply which best fits your usual habits. Monthly or less  2-4 times a month  2-3 times a week  4 or more times a week  How many units of alcohol do you drink on a typical day? 1 unit = 0.5 pint of beer or lager of 4% strength or 25 ml spirits or 125 ml of wine 10% strength Units /Week ………………….. (note: most wines contain 9 units per bottle) How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year ? Weight Height Do you Smoker Ex-Smoker Never Smoked (average number (Date stopped ups? smoked/day) smoking) MEDICAL HISTORY: Have you ever had any of these problems? No Yes High Blood Pressure Heart Disease Stroke or mini stroke Diabetes
The Accessible Information Standard aims to ensure patients, or their carers, easily receive, access and understand information. If you have any communication needs relating to a disability, impairment or sensory loss, or anything else you feel may be relevant to your needs, please let us know below. You may also ask at Reception for a form to complete, which will help you give this information. CARERS Are you a Carer? No Yes A carer is someone who looks after a relative, friend or neighbour who could not manage without their help. If you are a carer then please specify the relationship of the person you care for eg parent, child, neighbour, friend ………………………………… HEALTH PROFILE: How often do you have a drink containing alcohol? Please tick the reply which best fits your usual habits.  Never  Monthly or less  2-4 times a month  2-3 times a week  4 or more times a week How many units of alcohol do you drink on a typical day? 1 unit = 0.5 pint of beer or lager of 4% strength or 25 ml spirits or 125 ml of wine 10% strength (note: most wines contain 9 units per bottle) ………………….. Units /Week How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year ? Weight Height Do you ups? Smoker (average number smoked/day) Ex-Smoker (Date stopped smoking) Never Smoked MEDICAL HISTORY: Have you ever had any of these problems? No Yes High Blood Pressure Heart Disease Stroke or mini stroke Diabetes
patient-registration-pack-2017.docx