Alcohol Questionnaire

Title

First Name (required)

Last Name (required)

Date of Birth (required)

Home Telephone

Work Telephone

Your Email

Home Address

Postcode

Mobile Number

Please answer the questions below taking into account the following:

1 drink = ½ pint of beer or 1 glass of wine or 1 single spirits

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

Q.1 How often do you have a drink containing alcohol?

Please selectNeverMonthly or LessTwo to Four times a weekTwo or Three times a weekFour or More times a week

Q.2 How many standard drinks containing alcohol do you have on a typical day?

Please selectNever1 or 23 or 45 or 67 to 910 or more

Q.3 MEN: How often do you have 8 or more drinks on one occasion?

Please selectNeverMonthly or LessTwo to Four times a weekTwo or Three times a weekFour or More times a week

Q.4 WOMEN: How often do you have 6 or more drinks on one occasion?

Please selectNeverMonthly or LessTwo to Four times a weekTwo or Three times a weekFour or More times a week