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Home
Support
Support Overview
Drugs
Alcohol
Find Help
Employers & Training
Employers
Training
Services
Services Overview
Areas we cover
Juice Bar
About us
About us
Our mission
Trustees
Work For Us
Volunteering With Us
Success stories
Recovery Games
Updates
Contact us
Alcohol screen test
* is a required field
1
Answer the questions below
Who advised you to take this test?*
Please select...
Myself
GP
Relative
Other Health Professional
Police/Probation
Other
2
Tell us about yourself
Area*
Please select...
North East Lincolnshire
North Lincolnshire
East Riding of Yorkshire
Rotherham
Doncaster
Hull
Other
Age*
Please select...
19 and under
20 - 29
30 - 39
40 - 49
50 - 59
60 - 64
64 +
Your name
Gender*
Please select...
Male
Female
Other
3
Questionnaire
How often do you have a drink? *
Never
Monthly or less
2 – 4 times per month
2 – 3 times per week
4+ times per week
How many standard alcoholic drinks do you have on a typical day when you are drinking? *
1 - 2
3 - 4
5 -6
7 - 9
10+
How often do you have 6 or more standard drinks on one occasion? *
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 in the last year have you failed to do what was expected of you because of drinking? *
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often in the last year have you needed an alcoholic drink in the morning to get you going? *
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often in the last year have you had a feeling of guilt or regret after drinking? *
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often in the last year have you not been able to remember what happened when drinking the night before? *
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Have you or someone 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 or a doctor or another health worker been concerned about your drinking or suggested you cut down? *
No
Yes, but not in the last year
Yes, during the last year
Submit
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