High Road Surgery, Wood Green-Registration form (please answer all questions)

(if you do not have a NHS number, enter 1122112211)
Male

Female

Nil
Yes No
 
Single

Married

Divorce

Widow

Yes No
Never Smoked Ex-Smoker current smoker
Do not drink Drink occasionally Regular
Never Ex-drug user Current
Injecting Smoking Oral Not Applicable
Nil
Nil
Nil
Not applicable Not known

Last smear test date:

at

result-

recommended by

someone online closest GP other
Yes No
Yes No

Audit-C Questionnaire

Please tick

Questions Scoring system Your Score
How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? 1 - 2 3 - 4 5 - 6 7 - 9 10+
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? Never Less than monthly Monthly weekly Daily or almost daily
Download the form and email to highroad.surgery@nhs.net. Attach photo ID(eg:passport, driving, licence or identity card) and proof of address(utility bill, bank statement, tenancy agreement, driving licence). If it is for a child under 16 attach the birth certificate and immunisation history.