We often need to ask your opinion and as part of our patient group you would be invited to comment, answer surveys or come to meetings on a specific issue. Would you like more information about how you could get involved? YES/NO Would you be interested in joining our patient panel? YES /NO Would you be prepared to be contacted occasionally about patient surveys? YES/NO ALCOHOL Alcohol can affect your health and interfere with certain medications and treatments, so it is important that we ask you some questions about your use of alcohol. Questionnaire below: your answers will remain confidential so please be honest. Questions 0 1 2 3 4 Score How often do you have a drink Never Monthly 2-4 times a 2-3 times a 4 or more containing alcohol? or less week week times a week How many standard drinks 1 or 2 3 or 4 5 or 6 7 or 8 10 or more containing alcohol do you have on a typical day when you are drinking? How often do you have 6 or more Never Less Monthly Weekly Daily or standard drinks on one occasion? than almost daily monthly How often during the last year Never Less Monthly Weekly Daily or have you found that you were not than almost daily able to stop drinking once you had monthly started How often during the last year Never Less Monthly Weekly Daily or have you failed to do what was than almost daily expected of you because of your monthly drinking? How often during the last year Never Less Monthly Weekly Daily or have you needed an alcoholic than almost daily drink in the morning to get monthly yourself going after a heavy drinking session? How often during the last year Less Monthly Weekly Daily or have you had a feeling of guilt or than almost daily remorse after drinking? monthly How during the last year have Never Less Monthly Weekly Daily or you been unable to remember than almost daily what happened the night before monthly because you had been drinking?
We often need to ask your opinion and as part of our patient group you would be invited to comment, answer surveys or come to meetings on a specific issue. Would you like more information about how you could get involved? YES/NO Would you be interested in joining our patient panel? YES /NO Would you be prepared to be contacted occasionally about patient surveys? YES/NO ALCOHOL Alcohol can affect your health and interfere with certain medications and treatments, so it is important that we ask you some questions about your use of alcohol. Questionnaire below: your answers will remain confidential so please be honest. Questions 0 1 2 3 4 Score How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a week 2-3 times a week 4 or more times a week How many standard drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 or 8 10 or more How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily 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 expected of you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often 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? Less than monthly Monthly Weekly Daily or almost daily How 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
1.%20%20SPCS_GMS1%20and%20New_Patient_Health_Questionnaire_(June%202016_Updated%20July%202017).docx