Alcohol Questionnaire

Your Contact Details

Title

First Name*

Last Surname*

Date of Birth* 

Home Telephone* 

Work Telephone 

Home Address*

Postcode*

Email*

Alcohol

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? SelectNeverMonthly or Less2-4 times a month2-3 times a week4 or more times a week

How many standard drinks containing alcohol do you have on a typical day?* Select1 or 23 or 45 or 67 or 89 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? SelectNeverLess than monthlyMonthlyWeeklyDaily

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