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Name and address

Title
First Name*
Last Name*
Date of Birth*
Address Line 1
Address Line 2
Town
County
Postcode

Contact details

Home Phone Number
Mobile Number
Work Number
Email Address*
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Clinical details

Height
Weight
Blood Pressure

Smoking

Do you smoke?
Never
Current smoker
Ex-smoker
Date stopped smoking

Drinking alcohol

How often do you have a drink containing alcohol?

How often?

How many units of alcohol do you drink on a typical day when you are drinking?

Units on a typical day?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Units on a single occasion?

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