Alcohol Questionnaire (Audit C)

This alcohol harm assessment tool consists of the consumption questions from the full alcohol use disorders identification test (AUDIT).

First name

Surname

Date of birth

Address

Postcode

Telephone

Mobile

How often do you have a drink containing alcohol?

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

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?

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

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

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

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

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

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

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

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Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whitevale Medical Group • 30 Whitevale Street, Dennistoun, Glasgow, G31 1QS.

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Key Information

Alcohol Questionnaire (Audit C)

Privacy Protection