Alcohol Questionnaire Alcohol Questionnaire Personal DetailsName First Last Email Enter Email Confirm Email Date of Birth DD slash MM slash YYYY Phone NumberYour Personal Alcohol ConsumptionHow 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 per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often do you have 8 or more units on one occasion? Never Less than monthly Monthly Weekly Daily or almost Privacy Consent I consent to the practice collecting and storing my data from this form. OptionalThis form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.
