Alcohol Questionnaire

If you have been advised by the surgery to submit an alcohol review please use this form.

Last Updated: 18/08/2020

Your Details

Name *

Address *

Date of Birth *

Phone Number

Email Address *

Alcohol Review

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

How many standard drinks containing alcohol do you have on a typical day?

1 - 2

3 - 4

5 - 6

7 - 9

10 or more

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

1 to 9

10 to 19

20 to 39

40 or more

Never

Less than monthly

Monthly

Weekly

Daily

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

Further Information

Accessibility
Cookie Policy
Data Processing Policy

Translate this website with google

This website uses cookies

We use cookies to improve user experience. Choose what cookies you allow us to use. You can read more about our cookies before you choose.

Strictly Necessary

Performance

Targeting

Functionality