Alcohol consumption review

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Amount of different types of drink representing one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

A total of 5+ indicated increasing or higher risk of drinking. As you have scored 5 or more, please now fill in the questions below.

How often during the last year have you found that you were not able to stop drinking once you had started? *

How often during the last year have you failed to do what was normally expected from you because of your drinking? *

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *

How often during the last year have you had a feeling of guilt or remorse after drinking? *

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Have you or somebody else been injured as a result of your drinking? *

No

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

No

Yes, but not in the last year

Yes, during the last year

Please note that the details you give will be used to update your medical records.

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