Alcohol Questionnaire for Adults

Please answer the questions in the short questionnaire to enable us to assess your alcohol consumption rate and offer advice if necessary.

Name *

First

Last

Date of Birth *

on day? have

Gender

Female
Male

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contact Numbers

Confirm Email

Alcohol Consumption

One drink = ½ pint of beer or one glass of wine or one single spirits. / One unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5*0.12=1.5units.

1. How often do you have a drink containing alcohol?

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