Alcohol

Review

Please only use this form if requested by the practice.

Alcohol Review

Alcohol Review

Only fill in this form if you have been asked by the practice to do so.

Or records indicate that we do not have up to date alcohol intake for you. Having this information helps us to offer the best care for you. Please complete the below.

Contact information

Your details.
Address
Town
County
Postcode

Alcohol Review

1= Never
2= Monthly or less
3= 2 - 4 times Per month
4= 2 - 4 times per month
5= 4+ times per week
1= 1 or 2
2= 3 or 4
3= 5 or 6
4= 7 to 9
5= 10+
1= Never
2= Less than monthly
3= Monthly
4= Weekly
5= Daily or almost daily
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