Hoveton & Wroxham Medical Centre - Update Your Records

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Please complete the online form below to update your details.

Contact Details

* - fields required

Title: Mr Mrs Miss Ms Dr Other

Forename: *
Middle Name:
Surname: *
Date of Birth: Format: dd/mm/yyyy *
House Name / Number: *
Street:
Town: *
City:
County:
Postcode: *
Home Telephone: *
Mobile Number:
Email Address: *
Repeat Email Address: *


What is your first language?
What is your ethnicity?
Are you allergic to any medications? (please state which ones)

Height & Weight

Height	feet	in	OR	cm

Weight	stone	lb	OR	kg

Waist	inches		OR	cm

Smoking

Have you ever smoked tobacco?

Yes

If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Alcohol

( 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)
How often do you have a drink containing alcohol?
How many standard drinks containing alcohol do you have on a typical day when drinking?
During the past year, how often have you found that you were not able to stop drinking once you had started?
During the past year, how often have you failed to do what was normally expected of you because of drinking?
During the past year, have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down?

Depression

Could you be depressed ?

Carer

A carer is someone who looks after an elderly person or someone who is disabled. We do not mean a carer of a child.

Are you a carer?

Yes

Additional Notes:

Please click the image of the book below and a green border will appear around it. Then please continue down this page. If you are unsure please click here to try another challenge.

GP Website from Wiggly-Amps Ltd. Total visitors:117736

Answer the questions, based on how you've been feeling in the past two weeks. Please note, this questionnaire is for information only and is not intended to replace a consultation with a health professional.	Not at all	Several days	More than ½ the days	Nearly every day
1. Have you found little pleasure or interest in doing things?
2. Have you found yourself feeling down, depressed or hopeless?
3. Have you had trouble falling or staying asleep, or sleeping too much?
4. Have you been feeling tired or had little energy?
5. Have you had a poor appetite or been overeating?
6. Have you felt that you're a failure or let yourself or your family down?
7. Have you had some trouble concentrating on things like reading the paper or watching TV?
8. Have you been moving or speaking slowly, or very fidgety, so that other people could notice?
9. Have you thought that you'd be better off dead or hurting yourself in some way?

If yes, please provide the following information:
	Caring Details:
	Permission Date:
	Relationship:

If no, when did you quit smoking?