Alcohol Questionnaire - Oakwood Lane Medical Practice

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

Alcohol Questionnaire for Adults

Name *

Date of Birth *

Home Telephone *

Work Telephone *

Email *

Mobile Telephone *

Address *

Address

City

State/Province

Zip/Postal

Country

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?