Daily Drinking Questionnaire

A short questionnaire that gathers alcohol consumption habits to support prevention efforts and encourage more responsible drinking.

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Full Name

First Name

Last Name

Email Address

Phone Number

Gender

Male Female Other

Age

How Often Do You Consume Alcoholic Beverages?

Never Monthly Weekly Daily

How Many Standard Drinks Do You Consume on a Typical Drinking Day?

Do You Have a History of Alcohol Abuse or Dependence?

Yes No

Have You Ever Experienced Negative Consequences Due to Alcohol Consumption?

Yes No

Do You Have a Family History of Alcoholism?

Yes No

Additional Comments

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