Alcohol Management

Do you have any medical conditions?

Yes

No

Do you have any alleriges?

Yes

No

Do you take any regular medication?

Yes

No

Are you pregnant, breastfeeding, or actively trying for a baby?

Yes

No

Not Applicable

Do you suffer from any of the following medical conditions?

Elevated ALAT (Alanine Aminotransferase) or ASAT (Aspartate Aminotransferase) (>3 times upper normal limit).
Kidney disease
Liver Disease
Rare hereditary problems of galactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption
Recent history of acute alcohol withdrawal syndrome (including hallucinations, seizures, and delirium tremens)
Severe depression, generalised anxiety disorder, psychosis, schizophrenia, suicide attempts, suicidal thoughts, self-endangering behaviour or any other psychiatric disorder.

Yes

No

Are you experiencing physical symptoms of alcohol withdrawal, such as hand tremors (the shakes), sweating, or anxiety? Do these symptoms occur when you attempt to stop drinking alcohol?

If yes, please describe the symptoms

Yes

No

Do you have current or recent opioid addiction?

If yes, please provide details

Yes

No

How often do you have a drink containing alcohol?

Never

Monthly or less

2 to 4 times per month

2 to 3 times per week

4 times or more per week

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

0 to 2

3 to 4

5 to 6

7 to 9

10 or more

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 ?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or less than daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

No

Yes, but not in the last year

Yes, during the last year

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

No

Yes, but not in the last year

Yes, during the last year

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