2 - 4 2 - 3 4+ How often do you have a drink Monthly times times times Never containing alcohol? or less per per per month week week How many units of alcohol do you drink on a typical day when you are 1 -2 3 - 4 5 - 6 7 - 9 10+ drinking? How often have you had 6 or more Less or units if female, or 8 or more if male, Never than Monthly Weekly almost monthly on a single occasion in the last year? daily Daily How often during the last year have Less or you found that you were not able to Never than Monthly Weekly almost monthly stop drinking once you had started? daily How often during the last year have Daily Less you failed to do what was normally or Never than Monthly Weekly expected from you because of your almost monthly daily drinking? How often during the last year have Daily Less you needed an alcoholic drink in the or Never than Monthly Weekly morning to get yourself going after a almost monthly daily heavy drinking session? Daily How often during the last year have Less or you had a feeling of guilt or remorse Never than Monthly Weekly almost after drinking? monthly daily How often during the last year have Daily Less you been unable to remember what or Never than Monthly Weekly happened the night before because almost monthly daily you had been drinking? Yes, Yes, but not during Have you or somebody else been No in the the injured as a result of your drinking? last last year year Yes, Yes, Has a relative or friend, doctor or but not during other health worker been concerned No in the the about your drinking or suggested that last last you cut down? year year Scoring: 0 7 Lower risk, 8 15 Increasing risk, – – 16 – 19 Higher risk, 20+ Possible dependenc Summary Care Record (SCR) The SCR is an electronic health record that can be accessed when you need urgent treatment from somebody than your own GP eg at A and E, or the GP out of hours service.
How often do you have a drink containing alcohol? Never 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 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 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 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 the last year Yes, during the 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 the last year Yes, during the last year Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependenc Summary Care Record (SCR) The SCR is an electronic health record that can be accessed when you need urgent treatment from somebody than your own GP eg at A and E, or the GP out of hours service.
Central-Surgery-New-Patient-Questionnairre.docx