Alcohol and Exercise Questionnaire

Please complete the questionnaire for your Health Check Appointment. If you do not want to attend for a check then we would appreciate having the completed form anyway.

Alcohol and Exercise Questionnaire

Alcohol and Exercise Questionnaire

Patient Details

Please use date format: DD/MM/YYYY

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

Physical Activity

Please tell us the type and amount of physical activity involved in your daily life: *

During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc. *
Cycling, including cycling to work and during leisure time *
Walking, including walking to work, shopping, for pleasure etc. *
Housework / Childcare *
Gardening / DIY *
How would you describe your usual walking pace? *


Smoking status: *
Please select one: *
Would you be interested in stopping smoking and/or attending a stop-smoke clinic? *