First Name

Surname

Date of Birth                                         Phone Number
                    
E-mail Address

Mobile Phone Number


What is your Height?

What is your Weight?

Smoking
Do you smoke?                                Yes    No

If yes, what do you smoke?           Don't Smoke Cigarettes Rolling Tobacco Cigars Pipe Other

If so, how much do you smoke per day?   

Would you like information on giving up smoking?
Yes    No

Alcohol

One unit is 10 grams of alcohol and can be found in:
Half a pint of Beer
Less than half a pint of Export Lager, Lager or Strong cider. (A 440ml can of cider =2.3 units)
A small glass of wine (a 75cl bottle contains between 7&9 units)
A small sherry (a 75cl bottle = 13 units)
A pub single measure of spirits (a 75cl bottle of whisky = 28 units)

How much do you drink per week (units)  

Allergies

Do you have any know allergies?


I accept the terms & conditions