ONLINE ALCOHOL TREATMENT ENQUIRY FORM You can use this form to give me more details about yourself, which means I can give you more detailed information about how I may be able to help you. You can include your email or telephone number (at the end of the questionnaire), and I can contact you to discuss your options. Please note that anything sent over the internet is not secure, and that this form is sent via a third-party site, so I don't ask for your full name and address. None of the fields are compulsory, you can answer in as much or as little detail as you wish. Obviously, The more detailed you are, the more useful it is. But I can always get more information from you if we speak on the phone or arrange a face-to-face meeting.
Your Details
Name (first name and initial of surname):
Age:
Gender:	Male Female
Where you live (city, town, county or postcode - not your address):
Your Drinking
How much, on average, do you drink daily?
What's the minimum you drink daily?
When was the last time you didn't drink for a whole day?
When was the last time you didn't drink for a whole week?
What's the longest period you've been without a drink in the last 3 years?
Are you taking any illegal drugs?	No Yes
If so, can you tell me some more?
AUDIT score: (see here - opens in new window):
SADQ score: (see here - opens in new window)
Do you shake, sweat or retch in the morning before you have a drink?	No Yes Sometimes
If you're able to tell me more about your drinking, please do so here:
Current Treatment
Are you currently getting any help or treatment for your drinking?	No Yes
If so, please tell me a little bit more about it, and if you find it useful:
Previous Treatment
Have you ever had an alcohol detox?	No Yes
Have you ever seen your GP about your drinking?	No Yes
Have you ever seen a specialist NHS or charity (eg Addaction, Turning Point) about your drinking?	No Yes
Have you ever been to an AA meeting?	No Yes
Have you ever been to a rehab clinic?	No Yes
Have you ever received any other sort of help or treatment with your drinking?	No Yes
Have you ever taken any illegal drugs?	No Yes
If the answer to any of these is yes, please tell me more here:
Health
Have you any current health problems?	No Yes
If so, please tell me more here:
Are you taking any prescribed medication?	No Yes
If the answer to any of these is yes, please tell me more here:
Your height (metric or imperial is fine):
Your weight (metric or imperial is fine):
Have you had any major health problems in the past?	No Yes
If so, please tell me a bit more:
Have you ever had a fit (a seizure) when you've stopped drinking?	No Yes
Have you ever suffered from depression?	No Yes
Have you ever suffered from anxiety?	No Yes
Have you ever suffered from any other mental health problems?	No Yes
Have you ever tried to kill yourself or hurt yourself?	No Yes
Have you ever seen a mental health professional?	No Yes
If the answer to any of these is yes, please tell me more here:
How would your describe you mood over the last few weeks?
Your Social Circumstances
Please tell me a little about your home circumstances: who do you live with, how are you getting on, are the people around you supportive of you getting help?
Are you working, how does drink affect work, or if you're not working what do you do with your time?
Have you, now or in the past, been in trouble with the law?
Contacting You (please note you can send your contact details separately to mark@markjay.co.uk if you'd rather not attach them to this questionnaire)
How would you like me to contact you?	email phone
Email address (will not be used for spam!):
Phone number:
Any other comments about contacting you (eg good time to call, is it OK to leave a message, etc)
Anything else?
Is there anything I haven't asked about that you'd like to add?