Alcohol Consumption Questionnaire - The Villages Medical Group

Alcohol Consumption

We ask that you fill this form in to the best of your knowledge to help keep your medical record accurate, and so that we can provide relevant support if needed.

Patient Details

Title

Name

Forename Surname

Date of Birth

NHS Number (if known) Optional

Mobile Number

Email Address

Alcohol Screening Questions

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?

How many standard drinks containing alcohol do you have on a typical day?

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

What's your total number of points? (This will automatically update) Optional

AUDIT-C Questionnaire

If you score more than 5 above, We kindly ask you fill in this section to understand you a bit better.

What is the score from the Screening Questions (This will automatically update) Optional

How often in the last year have you found you were not able to stop drinking once you had started? Optional

How often in last year have you failed to do what was expected of you because of drinking? Optional

How often in the last year have you needed an alcoholic drink in the morning to get you going? Optional

How often in the last year have you had a feeling of guilt or regret after drinking? Optional

How often in the last year have you not been able to remember what happened when drinking the night before? Optional

Have you or someone else been injured as a result of your drinking? Optional

Has a relative/friend/health worker been concerned about your drinking or advised you to cut down? Optional

What is the score from the AUDIT-C Questionnaire (This will update automatically) Optional

Final AUDIT score

What is the total AUDIT score. Optional

The audit score is now split into 4 categories, and are as follows: 1-7 = Lower Risk Drinking || 8-15 = Hazardous Alcohol Use || 16-19 = Harmful Alcohol Use || 20+ = Possible Alcohol Dependence.

Consent

Once we receive this form we may text / email / call you with information regarding alcohol consumption, do you consent to this?

Yes

How would you like us to contact you?

SMS Optional

Telephone Optional

Email Optional

None Optional