Alcohol Questionnaire – Thorne Moor Medical Practice

Alcohol Questionnaire
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of birth *

Day Month Year
Date
Tel: *
Email *
example@example.com
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?
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.
Consent *

I agree to the privacy policy
Should be Empty: