Your Health

It is time to look after your general health. Fill in the following questionnaires and the GPs can review your answers and we can offer advice and support if indicated. If you need help with giving up smoking please see the resources available from ‘Help Me Quit’.

Help Me Quit

Alcohol consumption questionnaire v1.001

About you

Full name(Required)

First Last

Home address(Required)

Postcode(Required)

Email address(Required)

Enter Email Confirm Email

Date of birth(Required)

Day

Month

Year

Preferred phone number(Required)

NHS number

Get help to find your NHS number online

Alcohol consumption - how many units of alcohol do you consume in a week?

Approximately - 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. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2 to 4 times / month

2 to 3 times / week

4+ times / week

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

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?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Part one score

A total of 5+ indicates increasing or higher risk drinking.

Alcohol consumption – part two

How often during the last year have you found that you were not able to stop drinking once you had started?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking?(Required)

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?(Required)

Yes, but not in the last year

Yes, during the last year

Score - part 2

0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total score for alcohol questionnaire

Total score

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Comments

This field is for validation purposes and should be left unchanged.

Smoking questionnaire v1.001

About you

Full name(Required)

First Last

Home address(Required)

Postcode(Required)

Email address(Required)

Enter Email Confirm Email

Date of birth(Required)

Day

Month

Year

Preferred phone number(Required)

NHS number

Get help to find your NHS number online

Smoking status

What is your smoking status?(Required)

Current smoker

Ex smoker

Never smoked

How much do you smoke?(Required)

<1 cigarette or gram/day or equivalent

1 to 9 cigarettes or gram/day or equivalent

10 to 19 cigarettes or gram/day or equivalent

20 to 30 cigarettes or gram/day or equivalent

40+ cigarettes or gram/day or equivalent

How long have you smoked?(Required)

Are you interested in advice on how to quit?(Required)

Yes

How much did you used to smoke?(Required)

<1 cigarette or gram/day or equivalent

1 to 9 cigarettes or gram/day or equivalent

10 to 19 cigarettes or gram/day or equivalent

20 to 30 cigarettes or gram/day or equivalent

40+ cigarettes or gram/day or equivalent

When did you stop smoking?(Required)

Less than a year ago

More than a year ago

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

I agree to the privacy policy.

Comments

This field is for validation purposes and should be left unchanged.

Alcohol consumption questionnaire v1.001

About you

Alcohol consumption - how many units of alcohol do you consume in a week?

Alcohol consumption – part two

Total score for alcohol questionnaire

Smoking questionnaire v1.001

About you

Smoking status

Helpful links

Further Info