Update Your Clinical Record Form

How to Use This Form

Ensure that you complete all steps of this form to successfully send us an update to your clinical record.

Please note that this facility is ONLY for telling us about important changes to your clinical record, such as height and weight, lifestyle factors, and other useful information, and is ONLY for patients who are registered with our practice. You should contact the surgery to tell us about any other changes.

You will also receive a notification email to your inbox confirming that the updates have been sent successfully. If you do not receive a confirmation, please check your Junk or Spam email folders before contacting the Practice.

Step 1: Personal Details

Please provide your personal details below so we can identify you on our system. You must complete all fields marked with *. Click next to proceed to the next step.

First Name *

Surname *

Email Address *

Date of Birth *

Phone Number

Mobile Number

Street Address

Locality

City/Town

Post Code

Step 2: Body Measurements

You can use this section to tell us about some measurements. Press next to proceed to the next step.

Height (feet)

Height (inches)

Weight (stones)

Weight (pounds)

Waist Circumference (centimetres)

Step 3: Smoking Status

You can use this section to tell us about your smoking status. Press next to proceed to the final step.

Have You Ever Smoked?YesNo

Are You a Current Smoker?YesNo

How Many Do You Smoke Each Day?

Would you like some help or advice to quit smoking?Yes, please contact me with options for quitting smokingNo, I am not interested in quitting smoking at this time

When did you quit smoking?

Step 4: Alcohol Consumption

You can use this section to tell us about your alcohol consumption. Press next to proceed to the final step.

Alcohol Volume Guide

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

MEN: How often do you have EIGHT or more drinks on one occasion?WOMEN: How often do you have SIX or more drinks on one occasion?NeverLess Than MonthlyMonthlyWeeklyDaily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?NeverLess Than MonthlyMonthlyWeeklyDaily

How often during the last year have you failed to do what was normally expected of you because of drinking?NeverLess Than MonthlyMonthlyWeeklyDaily

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?NoYes, On One OccasionYes, More Than Once

Step 5: Other Information

Please use this section to tell us a little more about yourself. Press next to proceed to the final step.

Are You a Registered Carer for Someone?YesNo

Name of Person You Care For

Relationship to You

Date You First Became a Carer

Are you allergic to any medication? If so, please tell us which ones.

Ethnicity

First Language (Spoken)

Step 6: Finish & Confirm

To submit your changes, please click the Submit Changes button. You will also need to consent to our GDPR policy.

GDPR Consent *

I agree to Llan Healthcare processing these updates to my clinical record and have read and accepted the terms of our privacy policy.

Please do not fill in this field.

Security

Our update your clinical record form is encrypted and secured by a 128bit SSL certificate, and sends your request information in the content of an email. Although this is sent ONLY to the Practice, we are unable to guarantee complete privacy during the transmission.

If you have any concerns with regards to using this service, please speak to the Practice about other methods of telling us about any updates to your clinical record.

What is GDPR?

The EU General Data Protection Regulation (GDPR) is the most important change in data privacy regulation in 20 years. GDPR fundamentally reshapes the way in which data is handled across every sector, from healthcare to banking and beyond.As part of our data privacy obligations, we have to ensure that when we collect information about you that we are fully compliant with GDPR. For more information, please see the Guide to the General Data Protection Regulation (GDPR) article on the ICO website .

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Llanrumney Medical Centre

Ball Road
Llanrumney
CARDIFF
CF3 5NP

Phone: 029 2079 2661

For information about Cosmetic Procedures, including Lip Fillers Cardiff and Anti-Wrinkle Treatments, see our Cosmetic Procedures page.

Wellbeing Hub @ Maelfa

Maelfa
Llanedeyrn
CARDIFF
CF23 9PN

Phone: 029 2073 1671

Quick Patient Poll

Which of our Online Services have you used?

Booking or cancelling appointments
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Updating my clinical record
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Wellbeing Hub @ Maelfa: 029 2073 1671  Llanrumney MC: 029 2079 2661