Alcohol Consumption Review

During these difficult times the Practice continues to encourage all Patients to seek our help when required. We are however facing a high level of demand which means that there may be a delay in responding to your request, all requests deemed by a Doctor to be urgent will be dealt with immediately. Thank you for your patience and understanding.

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

All messages will receive an email response (to the input address) – please check your email address given and junk/spam folder if you do not receive a response.

Alcohol Consumption Review

Alcohol Consumption Review

If you are human, leave this field blank.

About You

Please select which site you are registered at: * Please select an option... Old Cottage Hospital Stoneleigh Medical Centre Fitznells Manor Surgery Cox Lane Surgery

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

View your score