Greyland Medical Centre

0161 798 9818

Alcohol Questionnaire

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

Please note a red asterisk indicates a compulsory field.

By 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.

  • Date Format: DD slash MM slash YYYY
  • Alcohol

    1 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.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

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