Alcohol Questionnaire

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

The NHS recommends limiting the amount of alcohol consumed to within healthy limits. For men this is not more than 21 units per week, including no more than 3-4 units per day. For women this is 14 units per week, including no more than 2 to 3 units per day.

If you are concerned about your level of drinking or need help cutting down, please book an appointment with a doctor.

Name

Date of Birth

Address

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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?

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

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?

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All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Cartmel Surgery • Haggs Lane, Cartmel, Grange-over-Sands, Cumbria, LA11 6PH.

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