Lifestyle Questionnaire - Bridgend Group Practice

Please complete the form below so that we can update our records as it is a requirement from Welsh Government to hold this information on our patients.

For health advice please see the links below

Help to stop smoking

Free Bilingual Drug and Alcohol Helpline

Adult weight management services in Cwm Taf Morgannwg

Name of patient

Date of Birth

Post Code

Do you smoke?

Ydw

If yes – how many? If you would like help to quit, please click the blue link above

Do you drink alcohol?

Ydw

If yes – how much. If you would like to cut down please call the Free Bilingual Drug and Alcohol Helpline by clicking the blue link above

What is your height and weight to calculate your BMI

Height

Weight