Relationship(i.e.Spouse/Partner/Parent/Carer etc) ……………………………………. To receive any confidential NHS-related information about me either by phone or face to face from Perranporth Surgery. SIGNED: ……………………………………………………….. DATE: ………………………………………………………….... For Office Use: code as XaNwR Consent to share with a specified 3rd party Alcohol Consumption Scoring system Your FAST score 0 1 2 3 4 How often have you had 6 or more Daily Less units if female, or 8 or more if or Never than Monthly Weekly male, on a single occasion in the almost monthly daily last year? Only answer the following questions if the answer above is Never (0), Less than monthly (1) or Monthly (2). Stop here if the answer is Weekly (3) or Daily (4). How often during the last year Daily Less have you failed to do what was or Never than Monthly Weekly normally expected from you almost monthly daily because of your drinking? How often during the last year Daily Less have you been unable to remember or Never than Monthly Weekly what happened the night before almost monthly daily because you had been drinking? Yes, Yes, Has a relative or friend, doctor or but not during other health worker been No in the the concerned about your drinking or last last suggested that you cut down? year year
Relationship(i.e.Spouse/Partner/Parent/Carer etc) ……………………………………. To receive any confidential NHS-related information about me either by phone or face to face from Perranporth Surgery. SIGNED: ……………………………………………………….. DATE: ………………………………………………………….... For Office Use: code as XaNwR Consent to share with a specified 3rd party Alcohol Consumption FAST Scoring system Your score 0 1 2 3 4 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 Only answer the following questions if the answer above is Never (0), Less than monthly (1) or Monthly (2). Stop here if the answer is Weekly (3) or Daily (4). 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 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 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 the last year Yes, during the last year
Health%20Data%20Collection%20Pack%2016%20years%20and%20over.docx