Alcohol Questionnaire

Personal details

Title: *

Gender: *

First name: *

Last name: *

Date of birth: *

Mobile: *

Home telephone: *

Work telephone:

Email address: *

Post code: *

Address: *

Alcohol

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?: *How often do you have (Men: EIGHT / Woman: SIX) or more drinks on one occasion?: *

Total to Audit - C: {{ subTotal }}

A total of 5+ indicates increasing or higher risk drinking.
An overall total score of 5 or above is AUDIT-C positive.

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 from you because of your drinking?: *How often during the last year have you needed an alcoholic 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 you had been drinking?: *Have you or somebody else been injured as a result of your drinking?: *Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?: *

Total to Audit - C - Part 2: {{ total }}: Lower risk Increasing risk Higher risk Possible dependence