Alcohol Questionnaire Form - The Medical Centre

Alcohol Questionnaire

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

Title Optional

Name

First Last

Date of Birth

Phone Number

Email Address

Address

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

Alcohol Questionnaire

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