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Updating Your Clinical Record

Thank you for agreeing to help us keep our records current and accurate. Fields marked with an asterisk are compulsory.

 

Note:

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.

 

If this matter concerns you then you should use another method to notify us of your information.

Patient Details
Height & Weight etc

Your height (cms)

Your weight (kgs)

Waste size (cms)

Blood pressure

systolic  /

diastolic

Resting Pulse

bpm

Smoking
Have you ever smoked?
Do you smoke now?
There are plenty of options available to help you quit. Is this something you would like us to contact you about?
Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Other Information
Do you look after someone as a carer?
Do you agree to our terms and conditions?

Thank you . Your request has been submitted to our team.

Note that by using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your comment.

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Your IP address will be sent with your communication. In rare cases where abuse or criminal activity can be shown to have taken place this may be used by the authorities to trace you.

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