Alcohol & Smoking Questionnaire

If you are unsure about alcohol limit and unit guidelines then please visit Drinkaware for further information.

Even if you have never smoked, please complete the following form so that we can update our records.

If you would like help to stop smoking, then please enquire at Reception about booking into our ‘Stop Smoking’ Clinic or read the information on the NHS website.

Your Details

Full Name *

Date of Birth *

Address *

Email Address

Home Telephone Number *

Mobile Number

Your Alcohol Data

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

Your Smoking Data

Have you Ever Smoked *

Never Smoker

Current Smoker

Ex-Smoker

I confirm that the information that I have provided is accurate to the best of my knowledge and that I will update the surgery if there are any changes to my health *

Yes

How do we contact you?

Please confirm if you would be happy for the surgery to communicate with you by e-mail

Yes

I would like to receive text reminders

Yes

I confirm that I am a registered patient at Southam Surgery *

Fields marked with an asterisk (*) are mandatory

FAQs

About This Form

Please note that we will not respond to any medical information or questions received through the survey.

The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Are my details secure?

The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible.

We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. When you submit your information, it is safely transmitted over the web in an encrypted form and deciphered using the private key at its intended location.

Alcohol & Smoking Questionnaire

Your Details

Your Alcohol Data

Your Smoking Data

How do we contact you?

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