Alcohol Consumption Survey

Collects anonymous data on drinking habits to support clinical and research studies.

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Age

Gender

Ethnicity

Have you ever consumed alcohol?

Yes No

At what age did you start consuming alcohol?

Why did you start consuming alcohol?

Social pressure Curiosity Family influence Stress Other

Do you feel you are a normal drinker?

Yes No

How often do you drink?

Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week

Do you engage in binge drinking? ( 5 or more drinks in a sitting)

Yes No

In the last two weeks, how many times have you had 5 or more drinks at a sitting?

0 times 1-2 times 3-4 times 5 or more times

Are you always able to stop drinking when you want to?

Yes No

Have you ever passed out or experienced memory loss due to drinking?

Yes No

Do you ever drive after drinking?

Yes No

Do you drink to feel good/to function better?

Yes No

Do you have a history of alcohol or drug problems in your family?

Yes No

Have you ever become violent or aggravated while drinking?

Yes No

Have you ever gotten into trouble at work because of drinking?

Yes No

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