Online Survey Software | Qualtrics Survey Solutions

Thank you for your interest in learning more about your relationship with alcohol. After completing this form you will receive personalized information on how you can address your alcohol consumption based on your answers. Please answer honestly for the most accurate results/feedback.

Disclaimer

This screening tool is not intended to serve as a substitute for a complete substance use evaluation.

Email Address:

Please select the response that best fits your drinking.

Please select the response that best fits your drinking.
	Never	Monthly or less	2-4 times a month	2-3 times a week	4 or more times a week
How often do you have a drink containing alcohol?	Never	Monthly or less	2-4 times a month	2-3 times a week	4 or more times a week

NIH Standard Drink Size

Please select the response that best fits your drinking (see above for standard drink sizes).

Please select the response that best fits your drinking (see above for standard drink sizes).
	1 or 2	3 or 4	5 or 6	7 to 9	10 or more
How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	7 to 9	10 or more

Please select the response that best fits your drinking (see above for standard drink sizes).

Please select the response that best fits your drinking (see above for standard drink sizes).
	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often do you have six or more drinks on one occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
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 of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
How often during the last year have you needed a first 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 of your drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily

Please select the response that best fits your drinking.

Please select the response that best fits your drinking.
	No	Yes, but not in the last year	Yes, during the last year
Have you or someone else been injured because of your drinking?	No	Yes, but not in the last year	Yes, during the last year
Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?	No	Yes, but not in the last year	Yes, during the last year