Alcohol consumption questionnaire – Lilford & Pennington Park 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.
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.