Alcohol Questionnaire - Kippax Hall Surgery

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

Alcohol Questionnaire for Adults

Your Contact Details

Name

Prefix First Last

Date of Birth

Home Phone

Mobile Phone

Work Phone

Address

Street Address Address Line 2 City Postcode

Alcohol

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirit. 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? WOMEN: How often do you have SIX or more drinks on one occasion? Optional