Alcohol Questionnaire - updated 2022

If you have been advised by the surgery to submit an alcohol review please use this form.

Your Details

Name *

Address *

Date of Birth (dd/mm/yyyy) *

Email Address *

Mobile Phone Number

Landline Phone Number

Alcohol Review

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.

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Alcohol Questionnaire - updated 2022

Alcohol Questionnaire - updated 2022

Further Information