* = Indicates required information.

Your Details

Full Name:
*

Date of Birth (dd/mm/yyyy):
*

NHS Number:
*

Address:

Questions

1. How often do you have a drink that contains alcohol?
       Never
       Monthly or less
       2 - 4 times a month
       2 - 3 times a week
       4 + times a week

2. How many standard alcoholic drinks do you have on a typical day when you are drinking?
       1 - 2
       3 - 4
       5 - 6
       7 - 8
       10+

3. How often do you have 6 or more standard drinks on one occasion?
       Never
       Less than monthly
       Monthly
       Weekly
       Daily or almost daily

4. How often in the last year have you found you were not able to stop drinking once you had started?
       Never
       Less than monthly
       Monthly
       Weekly
       Daily or almost daily

5. How often in the last year have you failed to do what was expected of you because of drinking?
       Never
       Less than monthly
       Monthly
       Weekly
       Daily or almost daily

6. How often in the last year have you needed an alcoholic drink in the morning to get you going?
       Never
       Less than monthly
       Monthly
       Weekly
       Daily or almost daily

7. How often in the last year have you had a feeling of guilt or regret after drinking?
       Never
       Less than monthly
       Monthly
       Weekly
       Daily or almost daily

8. How often in the last year have you not been able to remember what happened when drinking the night before?
       Never
       Less than monthly
       Monthly
       Weekly
       Daily or almost daily

9. Have you or someone else been injured as a result of your drinking?
       No
       Yes, but not in the last year
       Yes, during the last year

10. Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down?
       No
       Yes, but not in the last year
       Yes, during the last year