The Brooke Surgery

20 Market Street, Hyde, SK14 1AT

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Telephone: 0161 368 3312

Alcohol Questionnaire

Personal Details
Title*
Gender*
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Mobile
Home Telephone
Work Telephone
Email*
Postcode*
Address*
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?*
Q1
How many standard drinks containing alcohol do you have on a typical day?*
Q2
How often do you have (Men: EIGHT / Women: SIX) or more drinks on one occasion?*
Q3
Audit-C Score
Comments
This field is for validation purposes and should be left unchanged.