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
Your Personal Alcohol Consumption

1 unit of alcohol

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
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.

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.

Asthmatics: Asthma Control Test – ACT

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.

Privacy Consent

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