Surname:                   Forename(s):   

Date of birth:              Marital Status: 

Address:        

Postcode:      

Home Telephone:      Mobile: 

Occupation:          

Ethnicity (e.g. White, Asian, Chinese):       First Language: 

Weight:                      Height: 

Smoking (tick box & enter details if necessary):

I have never smoked        I smoke on a daily basis        I gave up smoking in (year)

Carers:  Do you have anyone who looks after you?         Do you care for anyone else?

If you have ticked either of these boxes please ask for a carers registration form at Holbrook Surgery reception so you can be included on our carers register.

Alcohol:

How many units of alcohol do you drink per week?  units

Note on units:  1= single measure of spirits; 1.5= alcopop or can of lager; 2= pint of regular beer/lager/cider or glass of wine (175ml); 9= bottle of wine.

Now, please enter the appropriate score to the following questions:

Questions	Score: 0	1	2	3	4	Score
How often do you have an alcoholic drink?	Never	Monthly or less	2-4 times a month	2-3 times a week	4+ times a week
How many units do you have on a typical day when you are drinking?	1-2	3-4	5-6	7-8	10+
How often do you have 6 or more units on one occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
Scoring: total of 5+ indicates hazardous or harmful drinking					Total:

N.B. This form will be submitted via email and is not encrypted.  If you prefer we also have the same form in paper format available at reception.