Little Waltham & Great Notley Surgery Click Here to see our sites opening hours CQC Rating LANGUAGE Open Menu HOME FORM: ALCOHOL CONSUMPTION SELF-ASSESSMENT Alcohol Consumption Self-Assessment Please be aware that this page is not monitored regularly if it is urgent or for medication requests please telephone the surgery. Personal Details First Name: * Last Name: * Email: * Confirm Email: * Date Of Birth: * Phone Number: * Your Personal Alcohol Consumption How often do you have a drink containing alcohol?: * Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times per week How many units of alcohol do you drink on a typical day when you are drinking?: * 1-2 3-4 5-6 7-9 10+ How often do you have 8 or more units on one occasion?: * Never Less than monthly Monthly Weekly Daily or almost Privacy Consent This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form. Submit form Contact Details Little Waltham Surgery 30 Brook Hill Little Waltham Chelmsford CM3 3LL Telephone: 01245 360253 SystmOnline All you need to know about SystmOnline and the services it provides you and your family 24/7/365 READ MORE Friends & Family Test The NHS want you to have the best possible experience of care. Please give your feedback. READ MORE Newsletter Sign-Up SIGN UP Terms of UseCookiesMedical DisclaimerAccessibility © Tree View Designs Ltd 2021 We use cookies to help provide you with the best possible online experience. By using this site, you agree that we may store and access cookies on your device. Find out about our cookies. ACCEPT ALL COOKIES SHOW OPTIONS