Vitals & Lifestyle

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Patient's Details

Title: *

Ethnicity & Religion

Please specify the ethnic group you consider you belong to: *

Your Religion:

Do you speak English?:

Do you read English?:

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Lifestyle

Smoking Status: *

Are you interested in advice on how to quit?: *

Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

How often did you have a drink containing alcohol in the past year?: *

How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?: *

How often did you have six or more drinks on one occasion in the past year?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Vitals & Lifestyle

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