Please enable JavaScript in your browser to complete this form.Which practice are you registered with?Gray's Inn Medical PracticeThe Vauxhall SurgeryDaleham Gardens Health CentreFortune Green PracticeFirst Name *Last Name *Date of BirthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mobile Number *Email Address *Kilograms (kg)Pounds (lb)Blood Pressure ReadingSmoking StatusHow much do you smoke?Light Smoker (1-9/day)Moderate Smoker (10-19/day)Heavy Smoker (20-39/day)Ex-smokerNever Smoked TobaccoDropdownFirst ChoiceSecond ChoiceThird ChoiceSubmit
