*Title: Mr Mrs Miss Ms Dr

*Name:

Previous surname(s):

*Date of birth: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December

NHS number:

*Address
(including postcode):

*Home telephone:  *Mobile:

Email address:

*Town and country of birth:

*Ethnic group: Please select White British White Irish Other White Background White & Black Caribbean White & Black African Other Mixed Background Black Caribbean Black African Other Black Background Asian - Indian Asian - Pakistani Asian - Bangladeshi Other Asian Background Chinese Rather not say Other  if other, please specify:

*Previous doctor's name:

*Previous address in the UK:

If born outside the UK,
please provide date of entry: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December

Do you smoke?: Never  Ex-smoker  Current smoker

Cigarettes: No  Yes  I smoke(d) a day

Cigars: No  Yes  I smoke(d) a day

Rollups: No  Yes  I smoke(d) oz a week

Pipe: No  Yes  I smoke(d) oz a week

How often do you have a drink containing alcohol?:

Never  Monthly or less  2-4 times per month  2-3 times per week  4+ times per week 

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

1-2  3-4  5-6  7-8  10+ 

Females only - How often have you had 6 or more units on a single occasion in the last year?:

Never  Less than monthly  Monthly  Weekly  Daily or almost daily 

Males only - How often have you had 8 or more units on a single occasion in the last year?:

Never  Less than monthly  Monthly  Weekly  Daily or almost daily 

How often during the last year have you found that you were not able to stop drinking once you had started?:

Never  Less than monthly  Monthly  Weekly  Daily or almost daily 

How often during the last year have you failed to do what was normally expected from you because of your drinking?:

Never  Less than monthly  Monthly  Weekly  Daily or almost daily 

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?:

Never  Less than monthly  Monthly  Weekly  Daily or almost daily 

How often during the last year have you had a feeling of guilt or remorse after drinking?:

Never  Less than monthly  Monthly  Weekly  Daily or almost 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 or almost daily 

Have you or somebody else been injured as a result of your drinking?:

No  Yes, but not in the last year  Yes, during the last year 

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?:

No  Yes, but not in the last year  Yes, during the last year 

Have you had a smear?: Yes  No  N/A (If you are male, select this option)

Smear details: Where   Date

Result: Normal  Abnormal:   Unknown

Next of kin's name:   Relation to next of kin:

Next of kin's phone:

Next of kin's address: