All information supplied will be recorded in your confidential medical records.
Contact Details Smoking Alcohol
For the following questions please answer to the best of your knowledge.
We have provided a basic guide to alcohol content below to assist your completion.
A 750ml bottle of wine contains 10 units.
A standard(175ml) glass of wine contains 2 units.
A single small shot of spirits (25ml) contains 1 unit.
A standard 70cl bottle of spirits contains 28 units.
A pint of 3.6% strength lager/beer/cider contains 2 units.
A pint of 5.2% strength lager/beer/cider contains 3 units.
How many units of alcohol do you drink a week? How often do you drink alcohol? How many drinks or you drink on a typical day? How often have you had 4 or more drinks if female, or 6 or more if male, on a single occasion in the last year? Height & Weight - Please tell us your most recent measurements for the following (if known). Next of Kin Family History
The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?
Medication Allergies If Yes, please give details Past Medical History Please give details of any treatments/medical conditions. Carer Information History Special Circumstances
Please tick any/all that apply.
Military Veteran Communication Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you? We now need you to provide proof of your identification and your address. We ask for 2 things: Step 1
A photo of your passport or driving licence, as proof of your name;