Drs Ridley, Elphick, Thompson, Glennie, Kurian and Marshall Greystoke Surgery Morpeth NHS Centre The Mount Morpeth Northumberland NE61 1JX Tel: 511393 Fax: 01670 503282 Alcohol Screening Questionnaire Name Date of Birth Address NHS No (If Known) Please circle the answer that applies to you. Scoring system Your Questions score 0 1 2 3 4 2 - 3 4+ 2 - 4 How often do you have a drink containing Monthly times times times per alcohol? or less per per month week week How many units of alcohol do you drink on a 1 -2 3 - 4 5 - 6 7 - 9 10+ typical day when you are drinking? How often have you had 6 or more units if Daily or Less than female, or 8 or more if male, on a single Never Monthly Weekly almost monthly daily occasion in the last year? Many Thanks for your time, if you wish to discuss this with us please contact the practice on 01670 511393
Drs Ridley, Elphick, Thompson, Glennie, Kurian and Marshall Greystoke Surgery Morpeth NHS Centre The Mount Morpeth Northumberland NE61 1JX Tel: 511393 Fax: 01670 503282 Alcohol Screening Questionnaire Name Date of Birth Address NHS No (If Known) Please circle the answer that applies to you. Questions Scoring system Your score 0 1 2 3 4 How often do you have a drink containing alcohol? Monthly or less 2 - 4 times per month 2 - 3 times per week 4+ times per week 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 Many Thanks for your time, if you wish to discuss this with us please contact the practice on 01670 511393
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