Please list any serious illnesses, accidents, operations or hospital admissions. Please state the year, condition and hospital/operation. Are you a current smoker? * Not a current smoker Light cigarette smoker (1-9 cigs/day) Moderate cigarette smoker (10-19 cigs/day) Heavy cigarette smoker (20-39 cigs/day) Very heavy cigarette smoker (40+ cigs/day) Trivial cigarette smoker (less than one cig/day) Social smoker User of electronic cigarettes Never smoked tobacco Have you ever smoker in the past? * Ex-light cigarette smoker (1-9 cigs/day) Ex-moderate cigarette smoker (10-19 cigs/day) Ex-heavy cigarette smoker (20-39 cigs/day) Ex-very heavy cigarette smoker (40+ cigs/day) Ex-trivial cigarette smoker (less than one cig/day) Ex-social smoker Never smoker tobacco If you are a current smoker, were you aware that we can refer you to stop smoking clinics? Have you ever experimented with, become addicted to, or become dependent on drugs/prescription medication? How often do you have a drink that contains alcohol? * Never Monthly or less 2-4 times per month 2-3 times per week 4+ times a week How many units do you have on a day when drinking? * Teetotal 1-2 units 3-4 units 5-6 units 7-9 units 10+ units How often do you have six or more standard alcoholic drinks on one occasion? * Never Less than monthly Monthly Weekly Daily or almost daily Do you have any of the following long-term conditions? N/A Asthma COPD Diabetes Hypertension Ethnicity
You do not need to submit your ethnicity, however, the collection of ethnicity data is crucial in increasing understanding of the inequalities faced by different ethnic groups in order to improve the planning and delivery of services for those who identify as an ethnic minority.
Ethnic Background * Not stated White - British White - Irish White - Any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Any other Asian background Black or Black British - Caribbean Black or Black British - African Black or Black British - Any other Black background Other Ethnic Groups - Chinese Other Ethnic Groups - Any other ethnic group Not known Summary Care Records (SCR)
The summary care record (SCR) is an electronic record of important patient information, created from GP medical records. It can be seen and used by Health Care Professionals involved in the patient's direct care. These include, Ambulance Paramedics, hospital staff including Minor Injury Units and out of hours services. This can only be accessed by authorised personnel with your expressed consent