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ESDaP - European Society for Dermatology and Psychiatry

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Home
News
Contact
Language

Membership (Including Application Process)
The Psychodermatology Diploma
The Newsletter
The Next Congress
The Leaflets and Questionnaires
About Us
Links
Useful Documents and Latest Research

Alcohol Questionnaire

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

Last Updated: 18/10/2022

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.

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