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Clinical Details Form

Contact details
Height & Weight etc
Height
Weight
Waist
Blood pressure
Smoking
Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single of 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:

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Note:

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.