Lifestyle Questionnaire

We ask that you fill in the life-style information below so that we can update your medical records.

Name

D.O.B

Address

Telephone Number

Are you a smoker?

Yes

If yes, how many cigarettes do you smoke a week?

Are you an ex-smoker?

Yes

If yes, how many did you smoke per week?

We must advise you that smoking is bad for your health. To access the STOP SMOKING WALES service please telephone 0800 085 2219.

Do you drink Alcohol

Yes

What do you drink? Beer/Lager /Wine or Spirits

1 pint of beer/lager = 2 units, 1 large glass of wine = 2 units, single spirit = 2-3 units

How much do you drink?

The Government advises that people should not regularly drink more than the daily unit guidelines

Height

Weight

Blood Pressure (only if possible)

Thank you for your co-operation.