Do you have a carer? YES or NO Are you a carer for someone else? YES or NO If yes, please complete the form carer’s Have you ever served in the Armed Forces? YES or NO If yes, when was your discharge date? Do you have any allergies YES or NO If YES please state: – How much do you weigh? (kg) How tall are you? (cm) Have you ever smoked tobacco? Do you smoke now? If yes how many Yes/No Yes/No per day? Smoking is bad for your health, if you smoke now, would you like advice on how to stop smoking? Yes/ No How many units of alcohol do you drink in a week? Please state: 1 pint of lager = 2.3 units; 25 ml measure of spirits = 1 unit; 175 ml glass of wine = 2.3 units How much is too much? Alcohol Questionnaire (Age 16 years & above) - Questions Scoring system Your 0 1 2 3 4 Score How often do have a drink Never Monthly 2 4 2 3 4 + – – that contains alcohol? or less times per times per times month week per week How many standard alcoholic drinks do you have on a 1 2 3 4 5 6 7 8 10 + – – – – typical day when you are drinking? How often do you have 6 or Never Less than Monthly Weekly Daily or more standard drinks on one monthly almost occasion? daily Scoring: A total of 5+ indicates increasing or higher risk drinking.
Do you have a carer? YES or NO Are you a carer for someone else? YES or NO If yes, please complete the carer’s form Have you ever served in the Armed Forces? YES or NO If yes, when was your discharge date? Do you have any allergies YES or NO If YES – please state: How much do you weigh? (kg) How tall are you? (cm) Have you ever smoked tobacco? Yes/No Do you smoke now? Yes/No If yes how many per day? Smoking is bad for your health, if you smoke now, would you like advice on how to stop smoking? Yes/ No How many units of alcohol do you drink in a week? Please state: 1 pint of lager = 2.3 units; 25 ml measure of spirits = 1 unit; 175 ml glass of wine = 2.3 units Alcohol Questionnaire (Age 16 years & above) - How much is too much? Questions Scoring system Your Score 0 1 2 3 4 How often do have a drink that contains alcohol? Never Monthly or less 2 – 4 times per month 2 – 3 times per week 4 + times per week 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 + How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Scoring: A total of 5+ indicates increasing or higher risk drinking.