Please complete this form so we can have up to date information on a number of lifestyle factors. You may of been asked to complete this as part of your medication review or long term condition monitoring. Please answer the questions honestly. 

This is one unit of alcohol:

• Half pint of regular beer, lager or cider
• 1 small glass of wine
• 1 single measure of spirits
• 1 single measure of aperitifs
• 1 small glass of sherry

And each one of these, is more than one unit:

• Pint of regular beer/lager/cider (2 units)
• Pint of premium beer/lager/cider (3 units)
• Alcopop or can/bottle of regular lager (1.5 units)
• Can of premium lager or strong beer (440ml) (2 units)
• Can of super strength lager (440ml) (4 units)
• Glass of wine (175ml) (2 units)
• Bottle of wine (9 units)

For other links you might find useful: 

Once we have received your details we will amend your medical records accordingly. If necessary we may decide to contact you regarding your form.

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Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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