First Name:   Surname:  
NHS Number: Home Phone:   Email Address:  
 
Address
Post Code:
Height:   Feet Inches OR centimeteres  
Weight   Stone Pounds OR kilograms
Waist   Inches OR cm
   
Have you ever smoked:  
If YES, do you smoke now?  
  If YES, how many a day?
  If NO, When did you quit?
   
Are you allergic to medications?
What is your ethnicity?
What is your first language?