Alcohol Units

    Points in this section refer to your AUDIT-C score

    A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive.

    Did you score 5+
    Remaining AUDIT Questions

    Blood Pressure

    As part of our new patient health screening program we require a blood pressure recording for all new patients. You can measure the reading at home if you have a blood pressure machine or at a local pharmacy. Alternatively, if you have your latest blood pressure readings, please enter them here.

    Medical History

    Do you suffer with any of the following medical conditions?
    Have you ever been admitted into hospital as a result of your asthma?

    In the last month, did: You get daytime symptoms?

    Do you have sleeping difficulty because of your asthma?

    Does your asthma interfere with your usual activities (e.g housework, work/school/exercise)?


    Mental Health
    Mental Health conditions


    Diabetes type

    Do you have any disability, impairment or sensory loss?

    Medical Details

    Are you also under medication prescribed by hospital, outside the GP?

    If you have medications please ensure you book a routine appointment so your repeat prescription(s) can be set up BEFORE they are due - there is a lead time to routine appointments being available.

    Family History

    Have your parents, brothers or sisters suffered from any of the following medical conditions?





    Heart Disease



    Please provide details

    Additional Details

    Preferred Chemist

    Please specify name and location of chemist, as from 17th June 2014 all prescriptions will be sent electronically to your nominated chemist.

    The information you supply us will be used lawfully, in accordance with the Data Protection Act 2018. The Data Protection Act 2018 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.