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Breathlessness Review

If you have been invited to submit an alcohol consumption review, please complete this form.

Full Name:


Date of Birth:


Phone Number:


Email Address:


This is one unit of alcohol:



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



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


Please note that the details you give will be used to update your medical records.

I confirm that the information provided is accurate to the best of my knowledge.

I confirm that I am currently within the UK at the time of sending my enquiry.