Update of Basic Health Information Form

Please note this form is for providing answers to the basic health information questions detailed below ONLY. It should NOT be used for any other updates or queries to the practice.

Please answer any questions you are able to.

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Personal Details

Communication needs

Generic Health record updates

Family history of Cardiovascular disease >60:

Family history of Cardiovascular disease <60:

Your Personal Alcohol Consumption

1 unit of alcohol

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 do you have 8 or more units on one occasion?: *

Audit Score Result 0 - 7 (Lower Risk)

Low Risk - you have a score of ()

Your answers suggest you are at a lower risk of being dependent on alcohol.

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Your Personal Alcohol Consumption - Part 2

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

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

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

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

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

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

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

Audit Score Result 8 - 15 (Increasing Risk)

( Increasing Risk ) - you have a score of ()

Your answers suggest you are at an increasing risk of being dependent on alcohol.

Your drinking is dangerous to your health, increasing your risk of serious health problems including seven types of cancer, liver and heart disease, and high blood pressure. Unless you cut down you are at risk of damaging your health.

Audit Score Result 16 - 19 (Higher Risk)

(( Higher Risk )) - you have a score of ()

Your answers suggest you are at Higher Risk of being dependent on alcohol.

Your drinking is dangerous to your health. You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week. Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.

Audit Score Result 20+ (Possible Dependence)

(( Possible Dependence )) - you have a score of ()

Your answers suggest you are at High Risk of being dependent on alcohol.

Asthmatics: Asthma Control Test – ACT

During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?:

During the past 4 weeks, How often have you had shortness of breath?:

During the past 4 weeks, how often did your asthma symptoms ( wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?:

During the past 4 weeks, how often have you used your reliever inhaler (usually blue)?:

How would you rate your asthma control during the past 4 weeks?:

SCORE: 25 - WELL DONE!

WELL DONE!

Your asthma appears to have been UNDER CONTROL over the last 4 weeks.
However, if you are experiencing any problems with your asthma, you should see your doctor or nurse.

SCORE: 20 TO 24 - ON TARGET

ON TARGET

Your score is:

Your asthma appears to have been REASONABLY WELL CONTROLLED during the past 4 weeks.
However, if you are experiencing symptoms your doctor or nurse may be able to help you.

SCORE: LESS THAN 20 - OFF TARGET

OFF TARGET

Your score is:

Your asthma may NOT HAVE BEEN CONTROLLED during the past weeks.
Your doctor or nurse can recommend an asthma action plan to help improve your asthma control.

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Putneymead Group Medical Practice
266 Upper Richmond Road
Putney
London
SW15 6TQ

Telephone: 020 8788 0686
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Counselling Direct: 020 8394 5469
Out-Of-Hours: 111

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Update of Basic Health Information Form

Low Risk - you have a score of ()

( Increasing Risk ) - you have a score of ()

(( Higher Risk )) - you have a score of ()

(( Possible Dependence )) - you have a score of ()

WELL DONE!

ON TARGET

Your score is:

OFF TARGET

Your score is:

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