When we are offering services such as Stop smoking support, blood pressure monitoring, blood glucose reading it is useful for us to have more information about yourself. If you are already a patient of Abington Pharmacy we should have a record of any medication you take on a regular basis, so don't worry too much about that, but information with regard to your lifestyle is beneficial for you to gain the best from our services.

Simply complete the form below (we've tried to keep the questions to a minimum). Don't worry - we won't share your details with any other third party. We hate spam as much as you do!

1. * First Name : Please specify First Name.  
2. * Last Name : Please specify Last Name.  
3. * Address : Please specify Address.  
4. * Postcode : Please specify Postcode.  
5. Date of Birth :Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050  
6. * Telephone Number :
   Please specify Telephone Number.  
7. * Email :
   Please specify Email.  
8. 1. please mark preferred contact please mark preferred contact  

Additional Information

1. Name of GP :  
2. Address of GP :  
3. What is your Height? :  
4. What is your Weight? :  
5. Are You a Smoker? : YesNo   
6.   How many do you smoke/day? Please specify How many do you smoke/day?.  
7. Do you Drink? : YesNo   
8.   How many units/week? Please specify How many units/week?.  
9. Amount of exercise/week :  
10. Portions of fruits and vegetables eaten/day :
     
11. Are you diabetic? : YesNo   
12. Is this controlled by diet alone? : YesNo  Please specify Is this controlled by diet alone?.  
13. Please fill in your current medication for this or any other medical condition : Please specify Medication details.  
14. Do you suffer from High Blood Pressure? : YesNo   
15.   How is this controlled? Please specify How is this controlled?.  
16. Are you on any regular medication : YesNo   
17. Details : Please specify Details.  
18. Do you pay for your prescriptions? : YesNo   
19.   What is your exemption? Please specify What is your exemption?.