Family history (<60yrs) of any of the following conditions? Smoking Status: (please tick) If Yes, please state which family member has the condition. High Blood Pressure Yes Never Smoked Who: Stroke Yes Ex-Smoker When did you quit? Who: Ischaemic Heart Disease Yes Current Smoker How many do you smoke a day? Who: Diabetes Yes you like advice on quitting? Yes No Who: Do you suffer from any significant medical conditions? Allergies Please specify date of diagnosis & any medication you take for the condition. Asthma Date of diagnosis: Medication: Yes Are you allergic No to any Diabetes Date of diagnosis: Medication: (If yes, specify medicines? Type 1 Type 2 to the right) Mental Illness (specify): Date of diagnosis: Medication: Do you have Yes other allergies No Other condition(s): i.e. nuts, gluten, (inc. date of diagnosis) peanuts, certain (If yes, specify to the right) foods, etc.? Medication: Alcohol Awareness Audit Office Please tick against the appropriate answer 0 1 2 3 4 Use How often do you have a drink containing alcohol? Monthly or 2 - 4 times 2 - 4 times 4+ times per Never less Per month per week week How many units of alcohol do you drink on a typical day 1 - 2 3 4 5 6 7 9 10+ Audit C when you are drinking? – – – Total How often have you had 6 or more units if female, or 8 or Less than Daily or almost Never Monthly Weekly more if male, on a single occasion in the last year? monthly daily How often in the last year have you found you were not Less than or almost Never Monthly Weekly able to stop drinking once you had started? monthly daily How often in the last year have you failed to do what was Less than Daily or almost Never Monthly Weekly expected of you because of drinking? monthly daily How often in the last year have you needed an alcoholic Less than Daily or almost Never Monthly Weekly drink in the morning to get you going? monthly daily How often in the last year have you had a feeling of guilt Less than Daily or almost Never Monthly Weekly or regret after drinking? monthly daily How often in the last year have you not been able to Less than Daily or almost remember what happened when drinking the night Never Monthly Weekly monthly daily before? Have you or someone else been injured as a result of your Yes, but not in Yes, during the drinking? No the last year last year
Do you suffer from any significant medical conditions? Please specify date of diagnosis & any medication you take for the condition. Allergies Asthma Date of diagnosis: Medication: Are you allergic to any medicines? Yes No (If yes, specify to the right) Diabetes Type 1 Type 2 Date of diagnosis: Medication: Mental Illness (specify): Date of diagnosis: Medication: Do you have other allergies i.e. nuts, gluten, peanuts, certain foods, etc.? Yes No (If yes, specify to the right) Other condition(s): (inc. date of diagnosis) Medication: Family history (<60yrs) of any of the following conditions? If Yes, please state which family member has the condition. Smoking Status: (please tick) High Blood Pressure Yes Who: Never Smoked Stroke Yes Who: Ex-Smoker When did you quit? Ischaemic Heart Disease Yes Who: Current Smoker How many do you smoke a day? Diabetes Yes Who: you like advice on quitting? Yes No Alcohol Awareness Audit Please tick against the appropriate answer 0 1 2 3 4 Office Use How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times Per month 2 - 4 times per week 4+ times per week Audit C Total How many units of alcohol do you drink on a typical day when you are drinking? 1 - 2 3 – 4 5 – 6 7 – 9 10+ 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 Less than monthly Monthly Weekly Daily or almost daily 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 or almost daily 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 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 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 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 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