The Red and Green Practice

Waterside (Hythe) and Blackfield Health Centres

Southampton

Partners in the Primary Care Network (PCN)

Blackfield Health Centre

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Short Audit C

Please complete and submit the questionnaire below.

Depending on your result, you may be asked to compete a follow up questionnaire. For advice on alcohol support click here

Short Audit C Questionnaire

1. edit *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

2. edit *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

3. edit *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

If you do not wish to complete this alcohol screening, please tick this box to decline.

Please tick this box before submission to acknowledge that this form is being sent un encrypted via the world wide web.

The information you have completed in this form will be stored in the Wix Website Editing Software, which is accessed using the practice's Wix login via the world wide web, please tick this box to confirm you are happy for this information to be stored.

If you are not happy to tick the boxes above please write down your details as requested above and return it to the surgery.

Thank you for submitting, we will update your records

Please note that Red & Green Practice have no control over the content of any external site used in this website

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