Diabetes COPD Asthma Mental Health Problems Chronic Kidney Disease Stroke Depression Disease Hypertension Dementia This is one unit of alcohol… each of these is more than one unit …and Please sign and date below to confirm that the information you have provided above is accurate and correct. Signature Date..……………………………………………… ………….……………………………………………………… Scoring system Your FAST score 0 1 2 3 4 Daily How often have you had 6 or more units if Less or female, or 8 or more if male, on a single Never than Monthly Weekly almost occasion in the last year? monthly daily Daily How often during the last year have you Less or failed to do what was normally expected Never than Monthly Weekly almost monthly from you because of your drinking? daily How often during the last year have you Less been unable to remember what happened or Never than Monthly Weekly the night before because you had been almost monthly daily drinking? Yes, Yes, Has a relative or friend, doctor or other but not during health worker been concerned about your No in the the last last drinking or suggested that you cut down? year year Please print your full name if you are signing on behalf of the patient. ……………………………………………………………… Your relationship to the patient…………………………………………………………………………………………………………………………. If you would like this form in an alternative format, for example large print or easy read, or if you need help with communicating with us, for example because you use British Sign Language, please let us know. You can call us on 01458 272473 or email
Diabetes COPD Asthma Mental Health Problems Chronic Kidney Disease Stroke Depression Disease Hypertension Dementia This is one unit of alcohol… …and each of these is more than one unit 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 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 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 Please sign and date below to confirm that the information you have provided above is accurate and correct. Signature ………….……………………………………………………… Date..……………………………………………… Please print your full name if you are signing on behalf of the patient. ……………………………………………………………… Your relationship to the patient…………………………………………………………………………………………………………………………. If you would like this form in an alternative format, for example large print or easy read, or if you need help with communicating with us, for example because you use British Sign Language, please let us know. You can call us on 01458 272473 or email
BHC%20Pt%20Questionnaire%20-%20over%2013%20yrs.docx