Do you require an interpreter? Y N What Language do you prefer to read? help with this form and do not read ‘I was given any language’ What is your religion? Can you read English even if it is not your preferred Language? Y N About your health Height: Weight: Do you Cigarettes per day: smoke? Tobacco per day: Y N Never smoked Cigarettes per day: Ex smoker Date stopped: WANT HELP TO STOP SMOKING? - BOOK AN APPOINMENT WITH OUR NURSING TEAM How many units/drinks of alcohol do you drink per week? *A standard drink (unit) of alcohol (around 10mls or 8g) is contained in: - A small (125ml) glass of standard strength wine (12%) - A single (25ml) pub measure of spirits - Half a pint of normal strength beer or lager HIV SCREENING: As part of our registration process we offer all patients aged between 16
Do you require an interpreter? Y N What Language do you prefer to read? ‘I was given help with this form and do not read any language’ What is your religion? Can you read English even if it is not your preferred Language? Y N About your health Height: Weight: Do you smoke? Y N Cigarettes per day: Tobacco per day: Never smoked Ex smoker Cigarettes per day: Date stopped: WANT HELP TO STOP SMOKING? - BOOK AN APPOINMENT WITH OUR NURSING TEAM How many units/drinks of alcohol do you drink per week? *A standard drink (unit) of alcohol (around 10mls or 8g) is contained in: - A small (125ml) glass of standard strength wine (12%) - A single (25ml) pub measure of spirits - Half a pint of normal strength beer or lager HIV SCREENING: As part of our registration process we offer all patients aged between 16
Adult-Registration-Practice-Area-LARGE-PRINT-VERSION-updated-April-2018-1.docx