Health and Lifestyle Review

If you have been advised by the surgery to submit a Health and Lifestyle review please use this form.

About You

Please use this date format: DD/MM/YYYY.
If you don't provide an email address we won't be able to respond to you by email

Your Health Information

Smoking Review

Smoking leads to health problems such as cancer, heart disease and strokes. The benefits of stopping smoking include: better health, more money and cleaner air for those around you!

Do you want to stop smoking? Here is some advice on ways to quit smoking, local services and general tips:

Also visit for advice and support and stopping smoking.

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

Alcohol Consumption - Part 2

A total of 5+ indicated increasing or higher risk of drinking. As you have scored 5 or more, please now fill in the questions below.

Please note that the details you give will be used to update your medical records.