Update your medical records - The Beeches Medical Centre

Title

Surname *

Previous Surname

Forename(s) *

Date of Birth *

Email Address

Confirm Email Address

Current Home Telephone

Current Mobile Number

Current Address

City

County

Post Code

Previous Address if recently moved house

City

County

Post Code

Please inform us of any other family members that need their address amending following moving address

Family Member – Name

Would you like to receive text message reminders?

Yes

No

I am a Carer

I am not a Carer

Carer’s Details – If you are completing this form on behalf of somebody and you are their registered carer – Please tell us your name and contact details

What is your Smoking Status?

Never Smoked

Ex Smoker

Light Cigarette Smoker (1-9 per day)

Moderate Cigarette Smoker (10-19 per day)

Heavy Smoker (20-39 per day)

Very Heavy Smoker (40+ per day)

Electronic Cigarette User

I do not want to give this information

If you currently smoke, would you be interested in stopping smoking?

Yes – Please send me information and help to quit smoking

No – I am not interested in stopping smoking

Not Applicable

How many alcohol units do you consume per day?

I do not drink alcohol

I only ever drink occasionally

Light Drinker (1-2 units per day)

Moderate Drinker (3-6 units per day)

Heavy Drinker (7-9 units per day)

Very Heavy Drinker (More than 9 units daily)

I do not want to give this information

How tall are you?

How much do you weigh?

What is your blood pressure? For example: 120/80 mmHg

If you do not have a home BP machine or you do not know your blood pressure, then please come into the surgery and use our free BP machine located in reception. Please ask reception for a gold token.

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