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Height & Weight etc
 feet   in OR  cm
 stone  lb OR  kg    
       
 (systolic) /  (diastolic)
(beats per minute)
Smoking
  
If 'Yes', please answer the following:
  
There are plenty of options available to help you quit. Is this something you would like us to contact you about?  
Alcohol
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.
Other Information
 
If yes, please provide the following information:  
 
 
 
  
 

Additional information