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Alcohol Questionnaire

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

Your Contact Details

Title

First Name*

Last Surname*

Date of Birth* 

Home Telephone* 

Work Telephone [number work-tel]

Home Address*

Postcode*

Email*

Alcohol

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?