Please state any Sensory Impairment you have (i.e. Speech, Hearing, Sight): Are you an ‘Assistance Dog’ User? Please state any Physical disabilities you have: Please state any Mental disabilities you have: Please state any requirements you have to be able to access the Practice premises Please state any Religious or Cultural needs: Please state any specific nutritional requirements you have: Please state any allergies and sensitivities you have: Please state any phobias you have: If you are a Carer, please state the name / address / phone number of the person you care for: Person Cared For Contact Details: If you have a Carer, please state their name / address / phone number and sign here if you wish us to disclose information about your health to your Carer. Carer Contact Details: Signed: Date: Do you have a “Living Will” (a statement explaining what medical treatment you would not want in the future)? Yes / No If “Yes”, can you please bring a written copy of it to your New Patient Consultation Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)? Yes / No If “Yes”, please state their name / address / phone number: Women only: When was your last smear done? Date: Was this at your GP’s Surgery? Yes No
This is one unit of alcohol… …and each of these is more than one unit AUDIT – C Questions Scoring system Your score 0 1 2 3 4 How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4+ 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 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 Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. Score from Previous page Remaining AUDIT questions Questions Scoring system Your score 0 1 2 3 4 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? Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? 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 Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence TOTAL Score equals: AUDIT C Score (prev.page) + Score of remaining AUDIT questions (this page)