V6 New Patient Questionnaire

Last Updated: 20/05/2022

Your Contact Details













Next of Kin


Information About You




Medical Information








Carers



Smoking





Alcohol

1 unit of alcohol = 1/2 pint of regular beer, lager or cider or 1/2 a small glass of wine or a single measure of spirit, sherry or aperitifs

1.5 units of alcohol = 1 Alcopop or a 275ml bottle of regular lager

2 units of alcohol = 1/2 pint of "strong or premium" beer, lager or cider

3 units of alcohol = 250ml glass of wine (12%) or 1 pint of "strong or premium" beer, lager or cider

4 units of alcohol = 440ml can of "super strength" lager

9 units of alcohol = 75cl Bottle of wine (12%)

 




Family History


Covid and Flu Vaccination History



Contacting You


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