ALCOHOL SCREENING Do you drink alcohol? Yes/No (delete as appropriate) If yes, please answer the following questions and tick the best that applies to you: 1 drink = ½ pint of beer, 1 glass of wine or 1 single spirit MEN: How often do you have Never Less than Monthly Weekly or monthly almost EIGHT or more drinks on one ( ) ( ) ( ) ( ) daily occasion? ( ) WOMEN: How often do you 0 1 2 3 4 have SIX or more drinks on one occasion? Never Less than Monthly Weekly Daily or monthly almost How often during the last ( ) ( ) ( ) ( ) daily year have you been unable to ( ) remember what happened the night before because you had 0 1 2 3 4 been drinking? Less than Monthly Weekly or monthly almost How often during the last ( ) ( ) ( ) ( ) daily year have you failed to do ( ) what was normally expected 0 1 2 3 4 of you because of drinking? In the last year has a relative, No Yes, on one Yes, on occasion more than friend, doctor or other health ( ) ( ) one worker been concerned about occasion your drinking or suggested ( ) you cut down? 0 2 4 Total for each column: ( ) ( ) ( ) ( ) ( ) Score: ( ) if score is >3 complete full audit Section 6 DECLARATION I declare that the above information is accurate and as up to date as possible. I understand that giving false information can delay my medical records being received from the Health Authority. It also constitutes an irrevocable breakdown in communication; this may lead to me being removed from the practice list. Signature of patient: Date: It is a requirement of this practice that all patients over the age of 5 are asked to attend a New Patient Check once they are registered with us (this is a 10 minute appointment with the Nurse).
ALCOHOL SCREENING Do you drink alcohol? Yes/No (delete as appropriate) If yes, please answer the following questions and tick the best that applies to you: 1 drink = ½ pint of beer, 1 glass of wine or 1 single spirit 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? Never ( ) 0 Less than monthly ( ) 1 Monthly ( ) 2 Weekly ( ) 3 or almost daily ( ) 4 How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never ( ) 0 Less than monthly ( ) 1 Monthly ( ) 2 Weekly ( ) 3 Daily or almost daily ( ) 4 How often during the last year have you failed to do what was normally expected of you because of drinking? ( ) 0 Less than monthly ( ) 1 Monthly ( ) 2 Weekly ( ) 3 or almost daily ( ) 4 In the last year has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? No ( ) 0 Yes, on one occasion ( ) 2 Yes, on more than one occasion ( ) 4 Total for each column: ( ) ( ) ( ) ( ) ( ) Score: ( ) if score is >3 complete full audit Section 6 DECLARATION I declare that the above information is accurate and as up to date as possible. I understand that giving false information can delay my medical records being received from the Health Authority. It also constitutes an irrevocable breakdown in communication; this may lead to me being removed from the practice list. Signature of patient: Date: It is a requirement of this practice that all patients over the age of 5 are asked to attend a New Patient Check once they are registered with us (this is a 10 minute appointment with the Nurse).