Name *

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Signature *

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Name *

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Date *

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Name of Child *

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Are you a carer?

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Have you previously been registered at this surgery?

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Have you had a mammogram?

Yes

No

How many days, per week, do you have a drink containing alcohol?

Never

1-2

3-4

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Every Day

How many standard drinks containing alcohol do you have on a typical day when drinking?

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How often do you have six or more drinks on one occasion?

Never

Less than monthly

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If you are a smoker, would you like advice to stop?

Yes

No