submit your health information

You can use the form below to keep us up to date with your current drinking and smoking habits.

If you are are a smoker, we can help you quit!

Please phone us on 01274 568383 and ask for a "stop smoking" appointment with one of our nurses. They can give you advice about how best to stop, and provide prescriptions for nicotine replacement products or medication to help you.

what is a unit of alcohol?

Wine (13% ABV)	1.5 units per small (125ml) glass 9 units per bottle (75cl)
Beer (varies)	Mild (3.6%) – 2 units per pint Medium (5%) – 3 units per pint
Sherry, Port (20%)	1 unit per pub measure (50ml) 15 units per bottle (75cl)
Whisky, Vodka (37.5%)	1 unit per measure (25ml) 26 units per bottle (70cl)

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forename *

surname *

date of birth *

E-mail address: *

postcode *

how many units of alcohol do you drink each week?

I have never smoked on a regular basis

I am an ex-smoker

I am still smoking

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