Alcohol Questionnaire – Pemberton Surgery

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

Full name*
Home address*
Postcode*
Date of birth*
DD slash MM slash YYYY
Home telephone*
Mobile telephone*
Work telephone*
Email address*
Enter Email Confirm 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?*
Consent*
I agree to the privacy policy.
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.
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