If you are willing to complete and submit this form to our secure NHS email, we would appreciate it as it helps us to identify patients in need of additional help from time to time.
Your name:
Your date of birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December year:
Your EMAIL address:
Your mobile phone number:
(We may be introducing a text message reminder service for appointments soon)
What is your approximate height?
How many times a week do you undertake exercise of 20 minutes or more?
If you drink alcohol most weeks, how much on average in a week?
if more than 30 units, please specify:
The following 4questions are designed to screen the population to find those who might need help with their alcohol...
1:How often do you have EIGHT or more units (SIX for women) on one occasion
(one unit is half a pint of beer or small glass of wine) Never less than monthly monthly weekly Daily or almost daily
2:How often during the last year have you been unable to remember what happened the night before
because you had been drinking?
3:How often during the last year have you failed to do what was normally expected of you
because of drinking
4:In the last year has a relative or friend, or a doctor or healthworker been concerned about your drinking or
suggested you cut down?
Would you like help to change your drinking habits?
Do you smoke / have you previously smoked?
Would you like help to change your smoking habits?
Do you currently use any illegal or "recreational" drugs?
Are you a carer for anyone else? No Yes if so, please would you let us have their details:
Now press the SUBMIT button to send the data securely to Dr Higson
