Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest.

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Which of the following applies to you?

Lifelong Teetotaller

Ex-drinker

Currently drink

• 1 unit = 1/2 pint beer/lager/cider (284 ml of 4% alcohol) or
• 1 pub single spirits shot (25 ml of 40%)
• 1.5 unit = 1 glass wine (125 ml of 12.5% of alcohol)

If you are currently drinking how many units of alcohol do you drink in a typical week?

Beer / cider:

Wine:

Spirit:

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 standard units of alcohol do you have on a typical day when you are drinking?

1 to 2

3 to 4

5 to 6

7 to 9

10 or more

How often have you had 6 or more units if female & 8 or more if male, on a single occasion in the last year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Useful links

• Calories in alcohol
• Tips on cutting down
• Alcohol units and guidelines
• The risks of drinking too much
• Alcohol misuse