Alcohol questionnaire

Surname

First name(s)

Telephone number

Email address

To be completed by patients aged 16 and over

alcohol graphic800

Please enter your score 0-4 against each question

How often do you have a drink containing alcohol? Never=0, Monthly or less=1, 2-4 times/month=2, 2-3 times/week=3, 4+ times/week=4

How many units of alcohol do you drink on a typical day when you are drinking? 1-2=0, 3-4 = 1, 5-6 = 2, 7-9 = 3, 10+ = 4

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4

If your total score above is higher than 5, please complete this section

How often during the last year have you found that you were not able to stop drinking once you had started? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4

How often during the last year have you failed to do what was normally expected from you because of your drinking? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4

How often during the last year have you had a feeling of guilt or remorse after drinking? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4

How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4

Have you or somebody else been injured as a result of your drinking? No=0, Yes but not in the last year=2, Yes during the last year=4

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No=0, Yes but not in the last year=2, Yes during the last year=4

Thank you for completing this form