Alcohol Questionnaire

Please answer the questions in the short questionnaire to enable us to assess your alcohol consumption rate and offer advice if required.

Title

First Name/s

Surname

Date of Birth

Address

Postcode

Home Phone Number

Work Phone Number

Mobile Phone Number

Email Address

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.

1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day?

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to White House Surgery • 1 Cheriton High Street, Folkestone, Kent, CT19 4PU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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