None Light Moderate Heavy Body Measurements Height Weight Waist Circumference cm kg cm YOUR SMOKING STATUS (Please tick boxes and complete with information as appropriate) Never Smoked N/A Ex-Smoker Date Stopped? Smoker How many per day? Would you like advice/help on Yes / No quitting? YOUR ALCOHOL CONSUMPTION Alcohol Each one of the below = 1 unit Scoring System (Circle your answers) Questions Your Score 0 1 2 3 4 How often do you have a drink Monthly 2 4 times 2 3 times 4+ times per – – containing alcohol? Never or less per month per week week How many of alcohol do you drink on a typical day when you 1 - 2 3 - 4 5 - 6 7 - 9 10+ are drinking? How often have you had 6 or Less more units if female, or 8 or Daily or Never than Monthly Weekly more if male, on a single almost daily monthly occasion in the last year? ADDITIONAL COMMUNICATION REQUIREMENTS (Tick all that Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record
None Light Moderate Heavy Body Measurements Height Weight Waist Circumference cm kg cm YOUR SMOKING STATUS (Please tick boxes and complete with information as appropriate) Never Smoked N/A Ex-Smoker Date Stopped? Smoker How many per day? Would you like advice/help on quitting? Yes / No YOUR ALCOHOL CONSUMPTION Alcohol Each one of the below = 1 unit Scoring System (Circle your answers) Questions 0 1 2 3 4 Your Score How often do you have a drink containing alcohol? Never Monthly or less 2 – 4 times per month 2 – 3 times per week 4+ times per week How many 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 ADDITIONAL COMMUNICATION REQUIREMENTS (Tick all that Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record