completing 3 AUDIT-C questions above) Your 0 1 2 3 4 Score How often during the last year have you found Less Daily or that you were not able to stop drinking once you Never than Monthly Weekly almost had started? monthly daily How often during the last year have you failed to Less Daily or do what was normally expected from you Never than Monthly Weekly almost because of your drinking? monthly daily How during the last year have you needed Less Daily or an alcoholic drink in the morning to get yourself Never than Monthly Weekly almost going after a heavy drinking session? monthly daily Less Daily or How often during the last year have you had a Never than Monthly Weekly almost feeling of guilt or remorse after drinking? monthly daily How often during the last year have you been Less Daily or unable to remember what happened the night Never than Monthly Weekly almost before because you had been drinking? monthly daily Yes, but Yes, Have you or somebody else been injured as a No not in last during result of your drinking? year last year Has a relative or friend, doctor or other health Yes, but Yes, worker been concerned about your drinking or No not in last during suggested that you cut down? year last year TOTAL: 3. Your Lifestyle - Continued Smoking Do you smoke? Never smoked Ex-smoker Yes Do you use an e-Cigarette? No Ex-User Yes How many cigarettes did/do you smoke a day? Less than one 1-9 10-19 20-39 40+ Would you like help to quit smoking? Yes No For further information, please see: Height & Weight Height Weight Women Only Do you use any contraception? Yes No If needed, please book appointment. Are you currently pregnant or think you may be? Yes No Expected due date: 4. Further Details Named Accountable GP The GP who has overall responsibility for your care is?
completing 3 AUDIT-C questions above) Your Score 0 1 2 3 4 How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily How during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily Have you or somebody else been injured as a result of your drinking? No Yes, but not in last year Yes, during last year Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in last year Yes, during last year TOTAL: 3. Your Lifestyle - Continued Smoking Do you smoke? Never smoked Ex-smoker Yes Do you use an e-Cigarette? No Ex-User Yes How many cigarettes did/do you smoke a day? Less than one 1-9 10-19 20-39 40+ Would you like help to quit smoking? Yes No For further information, please see: Height & Weight Height Weight Women Only Do you use any contraception? Yes No If needed, please book appointment. Are you currently pregnant or think you may be? Yes No Expected due date: 4. Further Details Named Accountable GP The GP who has overall responsibility for your care is?
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