Notes on medical re...
 

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[Closed] Notes on medical records - can anything to be done to change them?

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At some point in my medical history, I've been marked as alcohol dependant. I've never been alcohol dependant - I like a drink and drink too much, but I can cut it out altogether whenever I choose (and usually do a dry month or more every year), with no withdrawals.

Is drinking too much, technically alcohol dependancy?

The reason I'm bothered - it screws me over for life insurance when they check.


 
Posted : 25/05/2022 3:04 am
 hels
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Yes, in theory. You should put in a "right to rectification" request to the data controller, which is the organization who holds these records, I assume that is your health board or trust, or GP practice (England or Scotland? Different arrangements). They have a month to respond and correct the inaccuracies or explain why they believe this to be accurate which is of course subjective. Escalation via their Data Protection Officer and then Information Commissioner's Office.


 
Posted : 25/05/2022 5:49 am
 hels
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Thanks hels!!

And England


 
Posted : 25/05/2022 5:59 am
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You don’t think your life insurer should know that you, by your own admission, drink too much for up to 11 months of the year? You don’t think that will have any effect on your health?


 
Posted : 25/05/2022 6:24 am
 Spin
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You don’t think your life insurer should know that you, by your own admission, drink too much for up to 11 months of the year? You don’t think that will have any effect on your health?

And that's the problem with Web forums right there.

I don't know if STW is particularly bad for this but you can guarantee that if there's a judgemental comment to be made someone will make it.


 
Posted : 25/05/2022 6:33 am
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Let’s first assume that your notes really do say this.

Sometimes things are incorrectly noted on medical records. Corrections can be made. As folks have already described, you ask for the error to be corrected.

That you don’t like how a fact has been described in your medical records is different. Alcohol dependence appears to be a formal diagnosis in DSM-IV. You may want to discuss the criteria for diagnosis with your doctor and the accuracy of this diagnosis.

A couple of links
https://www.drinkaware.co.uk/facts/drinking-habits-and-behaviours/am-i-alcohol-dependent

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-use-disorder-comparison-between-dsm

Being labelled wrongly is not good. Being diagnosed correctly can help.


 
Posted : 25/05/2022 6:36 am
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You need to speak with your GP and have a discussion. Maybe show them that you haven’t had a drink for 6 months ? That would be a good way of proving you are not dependent on alcohol

By your own admission your life insurance should be weighted as you drink too much

https://www.nhs.uk/conditions/alcohol-misuse/

https://www.priorygroup.com/blog/signs-and-symptoms-of-a-functioning-alcoholic


 
Posted : 25/05/2022 6:43 am
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Not judgmental at all, they’re his life choices. Some life choices are a higher risk to insurers.


 
Posted : 25/05/2022 6:53 am
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You don’t think your life insurer should know that you, by your own admission, drink too much for up to 11 months of the year?

Judgemental: He doesn't say that he won't inform his insurer, IMO he says that it's the label "Alcohol Dependent" that should be considered

You don’t think that will have any effect on your health?

Judgemental: He doesn't suggest that either

Peace and goodwill, no negativity 🙂


 
Posted : 25/05/2022 7:13 am
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There's a difference between drinking too much and dependency.

Anyway I'm with @spin.


 
Posted : 25/05/2022 7:15 am
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There’s a difference between drinking too much and dependency.

Drinking too much is bad for your health so should cost more to insure.

When you apply for life insurance you answer a series of questions. The insurer then checks medical records. What a person thinks is dependence and what a medic might think are 2 different things.

In fact I would go as far as saying society as a whole plays down the effects of alcohol

There have been plenty of links shared above that give some insight.

Op needs to have an open and honest discussion with their gp


 
Posted : 25/05/2022 7:23 am
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I don’t know if STW is particularly bad for this but you can guarantee that if there’s a judgemental comment to be made someone will make it.

And this isn't judgemental?

What he said is factually accurate. It's just the other side of the coin.

It's for the OP to discuss with his GP to resolve, rather than us to jump in with keyboard diagnosis


 
Posted : 25/05/2022 7:35 am
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OP I'd suggest you take the test in one of the links above, I've just answered it based on my actual drinking habits (low risk thankfully) and then did it again based on 2 to 3 bottles of wine and a couple of beers a week (which isn't that unusual) and it comes out as high risk of dependency of alcohol. I don't think people recognise how serious "normal" drinking patterns that a lot of people have are.


 
Posted : 25/05/2022 7:36 am
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You can be alcohol dependent and still function well in life and you do not need to have withdrawals to be alcohol dependent

Its a lower threshold than people think.


 
Posted : 25/05/2022 7:38 am
 hels
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There will be a formal definition of "alcohol dependent" you may wish to arm yourself with this knowledge. This could just be a typing error, or you may have to get into a discussion about it. Either way, it is impacting your life and you have the right to question the accuracy.

You will also have to approach any other organisations that hold this information to have it corrected - I am not familiar with set-up in England sorry but records may be kept separately in different organisation.

Good luck - pm me if I can offer non-judgey help data protection is my field (health is not!)


 
Posted : 25/05/2022 7:40 am
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Another post has just disappeared into the Internet ether on hitting submit. Having to copy everything I type before hitting submit is really irritating. I'll precis my original post:

Declared alcoholic with 2 grams of alcohol in their blood when they stack = insurance coughs up. Declared non-drinker who lied on their form stacks with 2 grams of alcohol = insurance company sees a way out.

Being honest with insurance companies is a good idea if you want the insurance to be worth anything.


 
Posted : 25/05/2022 7:47 am
 mert
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Its a lower threshold than people think.

I "tested" positive for alcohol dependency whilst in final throes of a separation and eventual divorce.
Not due to the volume (as i drank relatively little, maybe maxing out at 15 units a week.) but due to the habits, reasoning and routines i'd gained around alcohol.

Thankfully, it was relatively easy to break the cycle as i realised that it was an issue myself, without anyone having to tell me.


 
Posted : 25/05/2022 7:56 am
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Am I missing something? He's never implied being dishonest, he's querying the term "dependency"
IANTAFKASTR


 
Posted : 25/05/2022 7:57 am
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Yes

The issue is how the medical profession and lay folk define dependency.

We do not know enough to judge ut the gp should


 
Posted : 25/05/2022 8:05 am
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Am I missing something? He’s never implied being dishonest, he’s querying the term “dependency”

The reason I’m bothered – it screws me over for life insurance when they check

So straight away what the OP submitted on his health questionnaire didnt agree to his medical record.

Doesnt mean he was being dishonest, and I dont think anyone has said that? Just that perhaps OP's medical understanding of alcohol consumption isnt that of a medic, or he didnt declare accurately on the form, or the medical diagnosis is incorrect.

Only OP and GP can work through the possible options.

It is helpful thing for us all though. After having COVID I was given a steroid inhaler. The nurse then put on my medical record I have asthma. I have had to do peak flow tests etc to now 'prove' I dont have asthma to get it taken off my record (as that would impact life insurance)


 
Posted : 25/05/2022 8:14 am
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Apologies for any insinuation of any potential dishonesty.

FWIW, due to my own choices, my medical history means I can’t get life insurance, and travel insurance is ferociously expensive, if I can get it.


 
Posted : 25/05/2022 8:14 am
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you can guarantee that if there’s a judgemental comment to be made someone will make it.

The OP asked for people's opinions:

Is drinking too much, technically alcohol dependancy?

He could have just asked the question "is there anything I can do to change my medical notes?" the fact that he chose to give details suggests that he was seeking affirmation that he doesn't have a medical issue with regards to alcohol.


 
Posted : 25/05/2022 8:22 am
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There are posters ^^ talking about being honest with insurers. He's never implied anything else.
Yes, there's a conversation to be had with the GP about "dependency" for reasons of health but also to ensure that his medical record is accurate. The ICO won't overturn correct use of the term, which is the topic of this thread

The sub-text of the topic is that alcohol is bad for health and I think that everyone knows that, but the OPs idea of "(I) drink too much" doesn't necessarily equate to "alcohol dependancy". None of us know the OPs drink usage and we shouldn't judge either his honesty or anything else

Anyway, I'm out 🙂


 
Posted : 25/05/2022 8:24 am
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And I'm back... we don't know what he submitted.
If he submitted alcohol units consumed below the threshold for alcohol dependency, but the doctor says that he is alcohol dependent, then there's an issue. The question that only one of us knows the answer to is where that issue lies. He's asking how to resolve that issue
Jeez you guys type fast...
Definitely out now


 
Posted : 25/05/2022 8:29 am
 DrP
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NICE states alcohol dependancy is:
Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences (for example, liver disease or depression caused by drinking).

I'm our practice IG lead - if you write to teh practice manage, and politely explain that though you drink "whatever", you don't demonstrate signs of dependancy.
Can your CODE be changed from dependancy to another alcohol code (drinks in excess, or simply the number of units).
Should be easy enough.

DrP


 
Posted : 25/05/2022 8:30 am
 jimw
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Is the record classed as an active or past problem on your medical records?
I am not sure if that makes a difference to Life insurance but it may be worth checking out


 
Posted : 25/05/2022 8:32 am
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Whether or not OP is drinking too much is a moot point. The definition of alcohol dependency is centred around an excessive desire to drink and withdrawal symptoms, which he says he does not have. The majority of heavy drinkers are not physically dependent.

I'm presuming you've requested and viewed your complete record, STR?

This is what you should expect from your GP Practice when you approach them regarding rectification.

https://www.gponline.com/responding-request-amend-patient-records/article/1462317

As Dr P says, they may well substitute in a different 'alcohol use' code, rather than a clean bill of health.


 
Posted : 25/05/2022 8:34 am
 DrP
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Anyway...It's a bit early for this sort of thinking... I'm gonna have a quick Irish coffee as a loosener then get back to work...

DrP


 
Posted : 25/05/2022 8:36 am
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🙂

Lightweight.


 
Posted : 25/05/2022 8:40 am
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That NICE definition could be interpreted very widely.

Craving? Yeah, I look forward to a drink sometimes.
In spite of harmful consequences? In the past I've had a bad head the next day, and I'm aware that all those carbs aren't good for me.

I would hope that I wouldn't be labelled as alcohol dependent, but using a very liberal interpretation of the rules, I suspect almost anyone could. I'm also with OP, I'd try and get it changed if that was on my record.

As a hospital doctor (that will often reference a patient's 'Summary Care Record' when I see them), I suspect that label has potential to influence treatment decisions.


 
Posted : 25/05/2022 8:49 am
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I had this a while back, when I was at Uni I answered the alcohol consumption questionnaire honestly and I was labelled as alcohol dependent (probably true at the time)

Five years later it was noticed when I moved job to one with private health insurance as a perk. I spoke to my GP and for a small charge they wrote a letter explaining I have no current issues with alcohol etc.


 
Posted : 25/05/2022 8:55 am
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I never realised you could look at your own records.

I'm worried they've got me down as some kind of 'drugs-seeker'. Years ago I was terrified of flying. I just avoided it for the most part but the occasional holiday would be ruined with anxiety unless I drank so much I was a danger to myself.

I decided that the responsible thing to do would be to go to the GP and ask for a couple of valium, which made it all bearable. Thinking a monitored prescription of two genuine tablets at the lowest dose a couple of times a year would be more sensible than buying a massive jar full off the internet. Anyway, they made it so hard and gave me so much bloody grief about it that I just bought a massive jar full off the internet.

This was years ago. Don't inactive issues drop off your record like CCJ's? 🙂


 
Posted : 25/05/2022 9:02 am
 DrP
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Anyway, they made it so hard and gave me so much bloody grief about it that I just bought a massive jar full off the internet.

They did the right thing, TBH... In teh 'good ol' days' GPs would dish out many 'bad' drugs left right and centre...created a legacy for more modern general practice to clean up...
It's not the right thing, leads to ongoing issues, and really CBT and other courses of action are the right thing for fear of flying.

See also:
sleeping pills
long term pain killers
etc etc

Sometimes the harded part of my job is refusing to be a 'legal drug dealer'!!!

DrP


 
Posted : 25/05/2022 9:13 am
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Can your CODE be changed from dependancy to another alcohol code

Could the wrong code have been used by mistake? As I understand it, notes are converted in codes by "coders"?


 
Posted : 25/05/2022 9:17 am
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From my days working at a PCT there was a perverse situation where GP's received extra payments for categorising people with certain conditions. It was financially worth while 'ticking the box'

Not sure if that still goes on ?

.... runs from the angry GP's 🙂


 
Posted : 25/05/2022 9:18 am
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They did the right thing, TBH… In teh ‘good ol’ days’ GPs would dish out many ‘bad’ drugs left right and centre…created a legacy for more modern general practice to clean up…
It’s not the right thing, leads to ongoing issues, and really CBT and other courses of action are the right thing for fear of flying.

See also:
sleeping pills
long term pain killers
etc etc

Sometimes the harded part of my job is refusing to be a ‘legal drug dealer’!!!

DrP

Huh, thanks for that. Especially interesting seeing it from the other side. That hadn't really occurred to me. I always knew they were dangerous drugs but didn't see the harm in a couple... I suppose at the time I just thought they were being over-dramatic because if they were that bad they would've been banned surely.


 
Posted : 25/05/2022 9:20 am
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 As I understand it, notes are converted in codes by “coders”?

nah, GP adds the problem to a new consultation and the coding is automatic depending on what they select when they discuss it with you. To be honest I've just scanned the codes for alcohol on EMIS and there are hundreds. All the way from self reported results to disorders.

Go chat with your GP and speak to them about your current status. If it's a old consultation that comes up on searches, it might still effect your insurance (dunno really i don't know what they look for) But GP can add a note to your record easily enough.


 
Posted : 25/05/2022 9:23 am
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 It was financially worth while ‘ticking the box’

The system encourages us to identify certain issues, but we're also expected to improve the health of patients once we've identified them!


 
Posted : 25/05/2022 9:30 am
 DrP
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As I understand it, notes are converted in codes by “coders”?

Yup - you're right. Coders are often non clinical so may read "billy bob says he drinks several pints a day and once was hung over" and type in "alcohol dependancy".
However, @nickc is also right - codes (i.e read codes) are added at multiple points in your patient journey.

Wanna hear somethng daft..
The year is 2022...
Your medical notes are all computerised....
BUt if you move to another GP practice, for some reason, some notes are "too large to go digitally" (i effing kid you not) to go "GP2GP" so they are printed out and posted and then re-entered at the receiving practice by hand. FFS.

Errors can occure when this happens.

Honestly - if you gave your NHS record control to Facebook it would be smart and seamless. Yeah, they'd harvest your data and organs, but it's be smoooth..

DrP


 
Posted : 25/05/2022 9:33 am
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It’s ok funkydunc we’ve never been financially incentivised to increase the number of alcoholics on our books…
Heart failure, hypertension, dementia etc etc etc yes, but alcohol dependence no.
As DrP says this is a pretty simple thing to sort out. Just contact the practice OP.


 
Posted : 25/05/2022 9:37 am
 jimw
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BUt if you move to another GP practice, for some reason, some notes are “too large to go digitally” (i effing kid you not) to go “GP2GP” so they are printed out and posted and then re-entered at the receiving practice by hand. FFS.

One of my jobs is doing just this. Also, if you move from Wales or Scotland to England there is a good chance the records don’t transfer…the systems don’t want to talk to each other. I agree with DrP, you would be shocked at how many records have to be amended when reconciling the electronic and paper notes. The records are only as good as the past coding. Still, keeps me employed I guess…


 
Posted : 25/05/2022 10:03 am
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BUt if you move to another GP practice, for some reason, some notes are “too large to go digitally” (i effing kid you not) to go “GP2GP” so they are printed out and posted and then re-entered at the receiving practice by hand

We requested our notes when we moved from one part of the country to another for this reason


 
Posted : 25/05/2022 10:24 am
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Thanks for all the replies - just got up after the night shift, so I'll pick through the bones of it later - but seems like I do need a chat with the GP

As most people have picked up on, I have no qualms admitting (declaring) that I drink too much, it's the term that is an issue - and yes, it's definitely defined as that on my records, the last broker I spoke to informed me. If it transpires that I am deemed to be dependant by my actions, fair enough - these are the lifestyle choices I have made. Having had a seriously alcohol dependant mother, there are huge differences between her alcohol usage and mine - to be labelled as the same in the eyes of insurers seems slightly inaccurate at best


 
Posted : 25/05/2022 12:24 pm
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nah, GP adds the problem to a new consultation and the coding is automatic depending on what they select when they discuss it with you.

Would a GP always advise the patient of what they've entered, or is there any reason that it might be withheld? And would such a blunt phrase always be used, or could it be couched, as GP : 'You really need to reduce your alcohol intake a bit'. Patient: 'Well, don't we all! Haha!'

(Of course, the GP might tell the patient that they are alcohol dependant but the patient might not actually be listening, but that's another thing..)


 
Posted : 25/05/2022 1:00 pm
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DrP

You mean you are not dr feelgood?


 
Posted : 25/05/2022 1:07 pm
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Would a GP always advise the patient of what they’ve entered, or is there any reason that it might be withheld

I GP would be better placed to advise. But certainly yes you should be fully aware that if you have a convo with your GP about depression, and that you both agree that you have been suffering from depression then it will be entered on your record.

As mentioned above, after having COVID I was given a steroid inhaler by the nurse. I was then noted as being asthmatic, which has only since been removed by me attending asthma clinic and doing peak flow tests etc.

The other side of it is that the insurance company interpret the medical record, and they can get it wrong. Mrs FD is prescribed a drug. I cant recall the drug or the condition it is used for, but basically the underwriter automatically assumes that she is taking the drug for the 1st use reason which then loads insurance premiums massively. In the past she has then had to challenge them (shes a doc) to say that they have jumped to the wrong conclusion.


 
Posted : 25/05/2022 1:33 pm
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I'm not a GP, but:

Would a GP always advise the patient of what they’ve entered

No, because that would be tedious at best. Half of the codes are stuff like "At risk of chronic kidney disease", "10 year CVS risk >5%" and "Smoking status: not entered this time".

or is there any reason that it might be withheld?

Doctors should always be aware that patients have the right to review their record, so you definitely shouldn't record things that you would not want them to see. Obviously this can be very difficult, especially with things like mental health and in particular when the individual might disagree with the GP's assessment.

There's obviously potential for breakdown in trust if the doctor writes something that the patient doesn't like, But of course most people don't bother to request access to their medical record, and it can be useful to record some things. Obesity would be an obvious one to record. This would be useful if the next GP is discussing, for example, joint pains over the phone where it might not be obvious the patient was 130kg.

The other side of it is that the insurance company interpret the medical record, and they can get it wrong. Mrs FD is prescribed a drug. I cant recall the drug or the condition it is used for, but basically the underwriter automatically assumes that she is taking the drug for the 1st use reason which then loads insurance premiums massively. In the past she has then had to challenge them (shes a doc) to say that they have jumped to the wrong conclusion.

That's interesting. I don't know how the actuaries adjust the risk (and therefore your premium) but I bet it's based on a huge statistical model that takes into account as much data as they can get their mitts on. If 95% of people who take Exampolol do so because they are really sick, presumably their formula decides Exampolol = more risk. Can the model account for the other 5%?


 
Posted : 25/05/2022 1:49 pm
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I would assume the automated process looks for drug names etc and links them to conditions. In my wifes case linking the drug to diabetes, and then loading her premium for being a diabetic... which she is not

Its only when she rings them stating why she takes the drug that they then review the under writing and the price drops significantly


 
Posted : 25/05/2022 1:55 pm
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I recently had a few nights in hospital and they asked the usual questions about smoking/drinking and I honestly answered that I usually drink two or three cans most nights. In the evening they came round with some tablets. I asked what they were for and was told they were to stop me having alcohol withdrawal symptoms. I was pretty shocked to be honest..........they could at least have brought me a couple of cans.


 
Posted : 25/05/2022 2:02 pm
 bfw
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A few years back I had to get my Dr to sign off a medical form for La Marmotte sportive. When he was sifting through my file I noticed something from 30 years ago, when I was 20 something I did something pretty daft after an end to a pretty horrible relationship, I was all good - but I did go to hospital.

30 plus years later those notes are still there, plus the x-rays from my bike accident in 85. I never imagined this. Now reading above that this is hand-typed up gives me the creeps...


 
Posted : 25/05/2022 2:12 pm
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and it can be useful to record some things. Obesity would be an obvious one to record.

This was in the back of my mind when I asked. Thanks for the replies - interesting stuff.


 
Posted : 25/05/2022 2:15 pm
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Honestly – if you gave your NHS record control to Facebook it would be smart and seamless. Yeah, they’d harvest your data and organs, but it’s be smoooth..

If often wondered why we don't take a Facebook-style approach to such things. With the correct access rights / authorisation levels, the whole thing would be very similar to Facebook / social media. You have a "wall" with current issues, etc. "notes" with older issues, "photos" with x-rays, test-results, etc. Anyone can log in from anywhere and can see whatever their autorisation level allows them to see.

Other things could be on the same platform (e.g. credit rating), again with appropriate access levels for appropriate users.


 
Posted : 25/05/2022 2:16 pm
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I've got "occasionally smokes crack" on my record.

I don't, never have - it's pretty far down the to-do list.


 
Posted : 25/05/2022 2:59 pm
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As mentioned above, after having COVID I was given a steroid inhaler by the nurse. I was then noted as being asthmatic

It's a shortcut. Coding you as asthmatic will prompt the tests that you've had done, and some other recalls and self completing text messages  just to keep an eye on you. There some pretty comprehensive Post Covid recalls now, so your GP/nursing teams should be using those.


 
Posted : 25/05/2022 3:13 pm
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If often wondered why we don’t take a Facebook-style approach to such things.

Starting to happen through the NHS app - I’ve most of my recent records on it in an bridged form and blood results etc. Most hospital clinic letters are copied to patients so they have a record and can correct any obvious errors (and thankfully they do) but of course GPs have very short multiple appointments compared to us in hospitals and probably haven’t the time to wipe their arses let alone write a summary letter. Suspect if we were able to increase the numbers of GPs and give them more patient facing time everyone would be lot better off.


 
Posted : 25/05/2022 3:27 pm
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Ooh I like that last sentence^^^^
I can’t think of many issues in the nhs that wouldn’t be lessened by more gps. With longer appointments and less patients. I do believe the current government promised this some time ago and has made zero progress towards it.


 
Posted : 25/05/2022 4:15 pm
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Wouldn't your insurer send round a nurse to do bloods and urine samples etc? Bloods would show if you had any liver issues related to alcohol. I once had insurance turned down cos I was drinking too much after a challenging diagnosis. My GP suggested that I take it easy for a couple of months and get bloods redone. Everything clear next time round.


 
Posted : 25/05/2022 4:32 pm
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Around 12 years I went for a medical prior to getting my private health insurance here in Munich.

All physical checks done and passed with a ja.
Doctor asks if I drink much. I said one or two beers a day on average. He joked and said I should consider that we're in Bavaria and I need to do my bit and filled in four.... 😁

Around 9 months ago I got a kidney stone. This doctor obviously asks me about my fluid intake. 5-6 beers a day during the week if in the workshop. Said in principle that's not a problem, but I should replace two of those Augustiner beers with a Weißbier or two, preferably midday.


 
Posted : 25/05/2022 5:47 pm
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Anyway, they made it so hard and gave me so much bloody grief about it that I just bought a massive jar full off the internet.

You wouldn't happen to have the name of the Ebay seller?

Asking for a friend 😉


 
Posted : 26/05/2022 3:32 pm

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