Alcohol Questionnaire Alcohol Questionnaire Name First Last Date of Birth DD slash MM slash YYYY Telephone NumberHow often do you have a drink containing alcohol? Never Monthly 2 to 4 times per month 2 to 3 times per week 4+ times per week How many standard alcoholic drinks do you have on a typical day when drinking? 1 to 2 3 to 4 5 to 6 7 to 9 10+ How often do you have six or more drinks on one occasion? Never Monthly Weekly Daily/Almost Daily During the past year, how often have you found that you were not able to stop drinking once you had started? Never Monthly Weekly Daily/Almost Daily During the past year, how often have you failed to do what was normally expected of you because of drinking? Never Monthly Weekly Daily/Almost Daily During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? Never Monthly Weekly Daily/Almost Daily During the past year, how often have you had a feeling of guilt or remorse after drinking? Never Monthly Weekly Daily/Almost Daily During the past year, how often have you been unable to remember what happened the night before because you had been drinking? Never Monthly Weekly Daily/Almost Daily Have you, or someone 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, a friend, a doctor, or another health worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year
