Alcohol Questionnaire

If you have been asked by the Practice to complete a questionnaire please complete and submit

Last Updated: 16/10/2020

Alcohol Questionnaire

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

Title *

First Name *

Last Name *

Address *

Postcode *

Date of Birth *

Contact telephone number *

Email address *

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

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Alcohol Questionnaire

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