Alcohol Consumption Review

If you have been invited to submit an alcohol consumption review, please complete this form.

Alcohol Questionnaire

Full Name

First Last

Date of Birth

Contact Number

Email Address Optional

2 units = 1 pint beer or 1 glass of wine (175mls),

1 unit = single measure of spirits,

1.5 units = alcopop or a can of Lager,

9 units = 1 bottle of wine.

How often do you have a drink containing alcohol?

How many drinks containing alcohol on a typical day when you are drinking?

How often do you have six or more drinks in one occasion?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected of you because of drinking?

How often during the last year have you needed a drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Has a relative , friend, doctor or other health care woerker been concerned about you drinking or suggested you cut down?

Total Score

If your score is above 8, please make an appointment to discuss your alcohol use or visit www.nhs.uk/live-well/alcohol-advice/alcohol-support/.