One Stop Questionnaire

If you have been asked to complete a One Stop Questionnaire by the practice please use this form.

Eastwick Park One Stop Questionnaire

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 alcoholAmount 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? *

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Smoking Status

Smoking status:

Online self referral for stopping smoking available from One You Surrey:
One You Surrey Stop Smoking Service

Your Blood Pressure

Please use date format: DD/MM/YYYY

Blood Pressure Reading:

If your readings are either above 140 systolic (top number) or above 90 diastolic (bottom number), please repeat two more times.

/
Is your reading either above 140 systolic (top number) or above 90 diastolic (bottom number)?

Blood Pressure, repeat 1:

/

Blood Pressure, repeat 2:

/

Please now book your 'One Stop' blood test

*