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Abbey Road Surgery NHS GP Surgery in Hertfordshire

Lifestyle advice for risk of diabetes

Section

Alcohol consumption

One unit of alcohol

Amount of different types of drink representing one unit of alcohol

More than one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

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

Alcohol consumption (part 2)

How often during the last year have you found that you were not able to stop drinking once you had started? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking? *

No

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

No

Yes, but not in the last year

Yes, during the last year

Diet

How would you rate your diet overall? *

Good

Average

Poor

Do you follow any of the below diets:

Food intolerance

Renal

Vegetarian

Vegan

Weight reducing

Weight gain

Please specify which foods you are intolerant to: *

Exercise

How much do you exercise? *

I take inadequate exercise

I enjoy moderate exercise

I exercise regularly

Measurements

Height (in metres): *

For example, 1.75

Weight (in KG): *

For example, 60.6

BMI:

Waist circumference (in centimetres):

Additional questions

Smoking status: *

Smoker

Ex smoker

Never smoked

Do you take any recreational drugs? *

Yes

No

Confirmation *

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

If you are human, leave this field blank.

Δ

63 Abbey Road
Waltham Cross
Hertfordshire
EN8 7LJ

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01992 654004

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