Personal Details

EMIS Number:*
Surname:*
Firstname:*
Date of Birth:*
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Mobile Tel.:
E-mail:*

Lifestyle Information

Height (cm):
Weight (Kg):
Smoking Status:
Quantity Smoked (Daily):
Do You Drink Alcohol?:
Number of Units per Week:

2 Units = 1 Pint of standard strength beer
1.6 Units = 1 Glass of white wine