Alcohol Questionnaire Alcohol Questionnaire for Adults Please fill in this questionnaire to the best of your knowledge. Your Contact DetailsName Title MrMrsMissMs First Last Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address Address Line 2 City Postcode Telephone NumberAlternative Telephone NumberEmail Enter Email Confirm Email Alcohol1 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.How often do you have a drink containing alcohol?NeverMonthly or Less2-4 Times per month2-3 Times a week4 or more times per weekHow many standard drinks containing alcohol do you have on a typical day?1 or 23 or 45 or 67 or 8More than 8Men: How often do you drink more than 8 drinks on one occasion ?NeverLess than MonthlyMonthlyWeeklyDailyN/AMen: How often do you drink more than 8 drinks on one occasion ? Women: How often do you drink more than 6 drinks on one occasion ?NeverLess than MonthlyMonthlyWeeklyDailyN/AWomen: How often do you drink more than 6 drinks on one occasion ? About this formBy using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your details. Personal Information Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.