Lifestyle Form - Llanishen Court Surgery

Name *

Address *

Alternative contact number (e.g. landline, work, relative). Please specify which.

Date of Birth *

Mobile phone number (if you have one)

Do you consent to being contacted by the practice via SMS (text message) with important clinical information (e.g. test results, appointment reminders) *

Yes No

Alcohol Review

Approx alcohol units for common drinks include:

WINE:

Small glass (125ml) - 1.5 Units
Standard glass (175ml) - 2 Units
Large glass (250ml) - 3 Units

BEER / LAGER / CIDER:

Pint of lower strength beer (3.6%) - 2 Units
Pint of higher strength cider / beer / lager (5.2%) - 3 Units
Standard strength 440ml can (5.5%) - 2.5 Units

SPIRITS (including gin, rum, vodka, whisky, tequila)

Single measure (35ml) - 1.4 Units

Weight and height

So that we can calculate your BMI, please could you provide us with your weight and height.

What is your height? You can answer in either imperial or metric measures. *

What is your weight? You can answer in either imperial or metric measures. *

Lifestyle Questionnaire

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Lifestyle Questionnaire

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