Roundwood Surgery

Wood Street, Mansfield, Nottinghamshire, NG18 1QQ | Tel: 01623 648880 | Fax: 01623 631761 | We're open

Forest Town Surgery, 47 Ellesmere Road, Forest Town, Mansfield, Nottinghamshire, NG19 0EG | Tel: 01623 648880 | We're open

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Updating Your Clinical Records

You are here:
Home
/
Updating Your Clinical Records

Updating Your Clinical Records

Updating Your Clinical Record

Contact Details
Name*
Prefix First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Home Phone Number
Mobile Phone Number
Email
Enter Email Confirm Email
Height & Weight
Height (ft/inches or in cm) - Please Specify
Weight (st/lbs or kgs) - Please Specify
Alcohol
MEN: How often do you have eight or more drinks in one occasion? WOMEN: How often do you have 6 or more drinks in one occasion?
Never Less than Monthly Monthly Weekly Daily
How often during in the last 12 - months have you been unable to remember what had happened the night before because you had been drinking?
Never Less than Monthly Monthly Weekly Daily
How often during the last 12 months have you failed to do what was normally expected of you because of drinking?
Never Less than Monthly Monthly Weekly Daily
In the last year has a relative or friend, or a doctor been concerned about your drinking or suggested you cut down?
No Yes, On One Occasion Yes, More Than Once
Smoking
Have you ever smoked?
- No
- Yes
Do you smoke now?
- No
- Yes
If 'No' when did you quit?
Other Information
Do you look after someone?
- Yes
- No
Caring Details - Relationship to the Person you care for.
Please Provide the following information.
Name
Prefix First Last
Are you allergic to any medications? (please state which ones).
- Yes
- No
Allergic to:-
Consent*
I agree to the privacy policy.
a)By contacting Roundwood Surgery you are agreeing to us storing your contact information on our secure servers.
b)We will only use your data to deal with your reason for contacting us.
c) Your data is stored on our secure NHS servers and information regarding data that is processed through our website servers can be https://surgeryweb.org.uk/privacy-policy/?utm_source=sendy&utm_medium=email
d)You can withdraw this consent at any time. Please contact the practice to do so.
This form collects only the information you imput into it, plus the time, date and IP address you are connected to.

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Roundwood Patients' Group

Patient Survey

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Self Care A-Z

Wood Street

Monday
08:30am - 18:30pm
Tuesday
08:30am - 20:00pm
Wednesday
08:30am - 18:30pm
Thursday
08:30am - 18:30pm
Friday
08:30am - 18:30pm
Saturday
CLOSED
Sunday
CLOSED

Forest Town

Monday
09:00am - 17:30pm
Tuesday
09:00am - 16:30pm
Wednesday
09:00am - 17:30pm
Thursday
09:00am - 16:30pm
Friday
09:00am - 16:30pm
Saturday
CLOSED
Sunday
CLOSED

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Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

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Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

Roundwood Surgery

Updating Your Clinical Records

Updating Your Clinical Record

Contact Details

Height & Weight

Alcohol

Smoking