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Charter
Medical Centre
88 Davigdor Rd
Hove
East Sussex
BN3 1RF

Telephone:
01273 770555

Fax:
01273 220883
 
 

 
 
 
 

Please use this form to tell us of your current state of health and wellbeing.
Remember this form is not for medical problems.

Your Name  
Date of Birth  
Your Address  
Your Post Code  
Your Telephone Number
(Landline and/or Mobile)		  
     
Occupation
(Name of school if under 16)		  
Your Height  
Your Weight  
     
Teetotaller / ex drinker  
Alcohol Consumption in Units per week.
Half a pint standard strength beer =1 Unit
Small glass of wine (125ml) =1 Unit
Single measure of spirits =1 Unit
Half a pint of high strength beer = 2 Units
Large glass of spirits = 2 Units
     
Smoking status
Never smoked
Ex-smoker
 
 
Smoker
How many cigs/oz tobacco per day?		  
 
 
If you look after a sick or disabled relative, friend or partner, you are a carer.
Are you a Carer?
Yes
No
 
How many hours a week are involved?  
     
Family History
Stroke
Emphysema
Asthma
High Blood Pressure
Heart Disease
Epilepsy
Diabetes
 
Diet
Vegetarian
Non Vegetarian
Vegan
 
     
Exercise Level
Exercise physically impossible
Inactive
Moderate
Vigorous
Gentle
 
Allergies: do you have any drug or food allergies?
Yes
No
 
If you have had any allergies please record them in the space provided and describe what happed.
(i.e. Swollen Face/Rash/Diarrhoea & Vomiting/Nausea.)		  
Please enter any other relevant health details or medical history in the space provided below.
 


         

 
 
 

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