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Scotch Quarter Practice

Carrickfergus Health Centre | Taylor's Avenue | Carrickfergus | Co. Antrim | BT38 7HT | Tel: 028 9331 5955

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Update Your Clinical Record

Update Your Clinical Record

Help us keep our records up to date. Fields marked with a red * are required.

Name *

First

Last

Date of Birth *

NHS No.

Telephone Number (Home)

Mobile Number

Email

Email

Confirm Email

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Height (feet/in or cm)

Please use either metric (cm) or imperial (feet/in)

Weight

Please use either metric (kg) or imperial (stones/lbs)

Waist

Please use either metric (cm) or imperial (inches)

Blood Pressure (Systolic)

Blood Pressure (diastolic)

Resting Pulse: beats per minute

Smoking

Have you ever smoked?

No
Yes

If yes, please answer the next question:

Do you smoke now?

No
Yes

If yes, please answer the next question:

How many do you smoke a day?

If you no longer smoke, when did you quit?

Would you like us to help you quit?

No
Yes

Alcohol

1 drink = ½ pint of beer or 1 glass of wine or 1 single spirits.

1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

Do you drink alcohol?

Yes
No

Your gender

Male
Female

How often do you have EIGHT or more drinks on one occasion?

How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

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

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

No
Yes, on more than one occasion

Other Information

Do you look after someone?

Yes
No

If you are looking after someone, please provide the following details:

Name of the person you are caring for

Permission Date

Your relationship

Are you allergic to any medications? (please state which ones)

What is your ethnicity?

What is your Nationality?

What is your first language?

Scotch Quarter Practice

Carrickfergus Health Centre
Taylor's Avenue
Carrickfergus
BT38 7HT
Email: [email protected]

Enquiries: 028 9331 5955
Appointments: 028 9331 5835
Emergencies: 028 9331 5834
Prescriptions: 028 9331 5837

Surgery Hours

Monday 08:30 - 17:30

Tuesday 08:30 - 17:30

Wednesday 08:30 - 17:30

Thursday 08:30 - 17:30

Friday 08:30 - 17:30

Saturday Closed

Sunday Closed

Out of Hours 028 2566 3500

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Login Designer
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Welcome to Our Practice Website

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IMPORTANT PATIENT NOTICE:

We are changing our clinical IT system between the dates of: 4th December and 11th December.
Please ensure you have ordered your prescriptions ahead of these dates. Please note there may be limited appointments available during this time.
We apologise for any inconvenience this may cause.