Alcohol Questionnaire Name * First Name Last Name Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Date of birth * - Day - Month Year Date Tel: * Email * example@example.com Alcohol1 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? * Please Select Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many standard drinks containing alcohol do you have on a typical day? Please Select 1 or 2 3 or 4 5 or 6 7 or 8 9 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? Please Select Never Less then monthly Monthly Weekly Daily Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website. Consent * I agree to the privacy policy Submit Should be Empty:
