Lifestyle Questionnaire

Help us to keep your details up to date by completing this questionnaire. Plase click the submit button when you have completed the questionnaire.

Personal Details

Title:
Mr	Mrs	Miss	Ms	Dr	Other

Name
Address Line 1
Address Line 2
Town
County
Post Code

Phone Numbers:
Home
Work
Mobile

DoB
Nationality
Marital Status
Are you a carer?	Yes No

Smoking Status
Never Smoked
Ex-Smoker	Date Ceased:
Smoker - Cigarettes per Day	1-9 10-19 20-39 40+
Smoker - Cigars per Day	1-10 11-20 20+
Pipe - Ounces Per Week	Ounces Per Week :
We offer advice on smoking and a smoking cessation clinic in the surgery. Please indicate whether you would like more information on this.
Yes No

Alcohol Consumption
Teetotaller
Drink Daily	Consumption Per Day :
Drink Weekly	Consumption Per Week :
( 1 unit = small glass of wine or ½ pint of beer or a normal measure of spirits )

Exercise Status
No Exercise Light Exercise Moderate Exercise Heavy Exercise
( walking everyday is light exercise )

Height
Weight
Blood Pressure
Not Sure? - We have a Health Monitor you can use to check your vital statistics! Please ask at reception.

Family History Status
	Relationship to You:
Heart Disease Aged 60 or Under
Heart Disease Aged Over 60
Diabetes
Hypertension / High Blood Pressure
Hyperlipidaemia / High Cholesterol
Cancer (Please State)