In an emergency call 999. Out-of-hours call 111. Askern Medical Practice: 01709 514443
Askern Medical Practice NHS general practice
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Askern Medical Practice

Help us keep your clinical record up to date

Complete this form and our team will process your request. We aim to respond within 2 working days.

This form is not for urgent problems. If you need help today, phone the practice on 01709 514443. In an emergency call 999.

Title
Address
What is your ethnicity? (optional)
(In Feet & Inches OR cm)
(In stone & lbs OR kg)
Have you ever smoked tobacco? (optional)If you are currently a smoker and would like to stop please contact the surgery to discuss this further.
How often do you have a drink containing alcohol? (optional)(1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)
How many standard drinks containing alcohol do you have on a typical day when drinking? (optional)
During the past year, how often have you found that you were not able to stop drinking once you had started? (optional)
During the past year, how often have you failed to do what was normally expected of you because of drinking? (optional)
During the past year, have you been unable to remember what happened the night before because you had been drinking? (optional)
Have you or somebody else been injured as a result of your drinking? (optional)
Has a relative, friend, doctor or health worker been concerned about your drinking or suggested you cut down? (optional)
Could you be depressed ? (optional)
Are you a Carer? (optional)

By sending this form you agree to the practice using the information above to process your request. See our privacy policy.