Alcohol Questionnaire - Wargrave House Surgery

Please answer the questions in the short questionnaire to enable us to assess your alcohol consumption rate and offer advice if necessary.

Alcohol Consumption Questionnaire Form

Alcohol Questionnaire for Adults

Your Contact Details

Title

Name

First Last

Date of Birth

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Contact Number

Email (Please provide an email address where possible)

Enter Email Optional Confirm Email Optional

Alcohol

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? Optional

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

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

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