Out Of Hours

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Contact Details
Name *			Date of Birth*
Address*			NHS Number
			Home Phone
			Mobile Phone
Postcode*			Email Address

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Height & Weight
Height	0 1 2 3 4 5 6 7  feet	0 1 2 3 4 5 6 7 8 9 10 11  in	OR	cm
Weight	stone	0 1 2 3 4 5 6 7 8 9 10 11 12 13 lb	OR	kg
Waist	inches		OR	cm

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Smoking
Have you ever smoked?	No	Yes
If 'Yes', please answer the following:
	Do you smoke now?   No  Yes
	If 'Yes' how many do you smoke each day?
	If 'No' when did you quit?

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Alcohol
( 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)
MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?	Never Less than Monthly Monthly Weekly Daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	Never Less than Monthly Monthly Weekly Daily
How often during the last year have you failed to do what was normally expected of you because of drinking?	Never Less than Monthly Monthly Weekly Daily
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?	No Yes, on one occasion Yes, more than once

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Other Information
Are you a carer?	No	Yes
If yes, please provide the following information:
	Caring Details:
	Permission Date:
	Relationship:
Are you allergic to any medications? (please state which ones)
What is your ethnicity?			Asian Black Mixed White Not stated / refused    British Irish Other
What is your first language?

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