WESSEX ROAD SURGERY



WESSEX ROAD SURGERY

ARE YOU AT RISK FROM DRINKING ALCOHOL?

As alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest. Please mark the box that best describes your answer to each question.

|Questions |0 |1 |2 |3 |4 |Score |

|1. How often do you have a drink |Never |Monthly or less|2-4 times a |2-3 times a |4 or more times a| |

|containing alcohol? | | |month |week |week | |

|2. How many drinks containing alcohol|1 or 2 |3 or 4 |5 or 6 |7 to 9 |10 or more | |

|do you have on a typical day when you| | | | | | |

|are drinking? | | | | | | |

|3. How often do you have six or more |Never |Less than |Monthly |Weekly |Daily or mostly | |

|drinks on one occasion? | |monthly | | |daily | |

|4. How often during the last year |Never |Less than |Monthly |Weekly |Daily or mostly | |

|have you found that you were not able| |monthly | | |daily | |

|to stop drinking once you had | | | | | | |

|started? | | | | | | |

|5. How often during the last year |Never |Less than |Monthly |Weekly |Daily or mostly | |

|have you failed to do what was | |monthly | | |daily | |

|normally expected of you because of | | | | | | |

|drinking? | | | | | | |

|6. How often during the last year |Never |Less than |Monthly |Weekly |Daily or mostly | |

|have you needed a first drink in the | |monthly | | |daily | |

|morning to get yourself going after a| | | | | | |

|heavy drinking session? | | | | | | |

|7. How often during the last year |Never |Less than |Monthly |Weekly |Daily or mostly | |

|have you had a feeling of guilt or | |monthly | | |daily | |

|remorse after drinking? | | | | | | |

|8. How often during the last year |Never |Less than |Monthly |Weekly |Daily or mostly | |

|have you been unable to remember what| |monthly | | |daily | |

|happened the night before because of | | | | | | |

|your drinking? | | | | | | |

|9. Have you or someone else been |No | |Yes, but not | |Yes, during the | |

|injured because of your drinking? | | |in the | |last year | |

| | | |last year | | | |

|10. Has a relative, friend, doctor or|No | |Yes, but not | |Yes, during the | |

|other health care worker been | | |in the last | |last year | |

|concerned about your drinking or | | |year | | | |

|suggested you cut down? | | | | | | |

| | | | | |Total | |

| | | | | | |/40 |

Name: Date of birth:

Scores of 8 or more are considered an indicator of hazardous and harmful alcohol use. Should you have any concerns about yourself or anyone else in this respect please feel free to book in to discuss it with one of the doctors. You can also self refer to our local SMART (Substance Misuse assessment and Referral Team) on 01202 735777. More information can also be found on .

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