Alcohol Audit O - The University Health Centre

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

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

0

1 - 2

3 - 4

5 - 6

7 - 8

10 or more

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 in the last 3 months? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last 3 months have you found that you were not able to stop drinking once you have started? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last 3 months have you failed to do what was normally expected of you because of your drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often in the last 3 months have you needed an alcoholic drink in the morning to get you going? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last 3 months have you had a feeling of guilt or regret after drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last 3 months have you been unable to remember what happened when drinking the night before? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

No

Yes, but not in the last 3 months

Yes, during the last 3 months

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 3 months

Yes, during the last 3 months

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

Alcohol Audit 0

Further Information

Alcohol Audit 0

Further Information

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