Update Health Records

If you have been advised by the surgery to do so, please submit this form.

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Update Health Records

Update Health Records



Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Do currently smoke section

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Blood Pressure (if known)


Please specify the ethnic group you consider you belong to: