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Kenilworth Medical Centre

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Getting Your Test Results
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Online Reviews and Assessments

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Our Staff

UPDATING YOUR CLINICAL REORDS

Last Updated: 14/11/2023

Height & Weight etc

FORENAME *

SURNAME *

PREVIOUS SURNAME

DATE OF BIRTH *

ADDRESS INCLUDING POSTCODE

PHONE NUMBER *

WEIGHT

HEIGHT

BLOOD PRESSURE

RESTING PULSE

ARE YOU ALLERGIC TO ANY MEDICATIONS

Yes No

IF YES PLEASE SPECIFY

SMOKING

HAVE YOU EVER SMOKED

Yes No

DO YOU SMOKE NOW

Yes No

IF NO WHEN DID YOU QUIT

ALCOHOL

1 Drink = 1/2 pint of beer or 1 small glass of wine or 1 single spirit measure.

MEN; How often do you have EIGHT or more drinks on one occassion WOMEN : How often do you have SIX or more drinks on one occassion

Never

Few times a year

Once a month

Once a week

More than once a week

How often during the last year have you been unable to remember what happened the night before because you had been drinking

Never

Few times a year

Once a Month

Once a Week

More than once a week

In the last year has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down

Yes No

CARER

Are your a carer for someone

Yes No

Who do you care for, name and your relationship to them

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