Update Clinical Record

Please help us to keep our clinical records up to date by providing the information below.

If you need help understanding the blood pressure recording please visit http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Bloodpressurechart

Your Details

Title

First Name

Surname

Date of Birth

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

Your Address

Address

Post Code

Your Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

Physical Attributes

HeightSpecify if in Feet & Inches or Centimetres

WeightPlease specify if in Pounds, Stones or Kilogrammes

Waist MeasurementPlease specify if in Inches or Centimetres

Blood pressure top/upper value

Blood pressure bottom/lower value

Lifestyle Choices

Have you ever smoked?

If yes to the previous question do you currently smoke?

If 'no' you don't currently smoke, when did you quit?

If you do currently smoke how many do you smoke a day?

There are plenty of options available to help you quit. Is this something you would like us to contact you about?

Do you drink alchohol?

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Additional Information

Are you a carer?

Are you allergic to any medications?

What is your ethnicity?

What is your first language?

Other Information

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Queens Road Partnership • 387 Queens Road, New Cross Gate, London, SE14 5HD.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Key Information

Update Clinical Record

Privacy Protection