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Drinking and Alcohol Use
Thank you for taking the time to complete this survey. Your responses will help us better understand drinking and alcohol use behaviors and how we can provide better support for those who may be struggling with alcohol use.
*1.
Have you had a drink containing alcohol in the past month?
Yes
No
*2.
How many days in the past month have you had a drink containing alcohol?
1-2 days
3-4 days
5-7 days
7-14 days
14-21 days
21+ days
I did not have a drink containing alcohol in the past month
*3.
How many drinks containing alcohol do you have on a typical day when you are drinking?
1-2 drinks
3-4 drinks
5 or more drinks
I did not have a drink containing alcohol in the past month
*4.
How often do you have six or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
*5.
In the past year, have you:
Yes | No | |
---|---|---|
Blacked out from drinking? | Yes
|
No
|
Missed obligations or responsibilities because of drinking? | Yes
|
No
|
Had problems with family or friends because of drinking? | Yes
|
No
|
Driven a vehicle after drinking? | Yes
|
No
|
*6.
Have you ever sought help for a drinking problem?
Yes
No
7.
If yes, what kind of help did you seek? (select all that apply)
Self-help group (e.g. Alcoholics Anonymous)
Professional counseling or therapy
Inpatient treatment program
Outpatient treatment program
Prescription medication
Other (please specify)
*8.
Were you successful in addressing your drinking problem?
Yes
No
9.
If no, what barriers or challenges did you encounter when trying to address your drinking problem?
Lack of support from friends or family
Withdrawal symptoms
Cravings
Stress or anxiety
Lack of motivation
Other (please specify)
10.
Is there anything else you would like to share about your drinking or alcohol use?
Thank you for your time and feedback. Your responses will help us improve our support for those struggling with alcohol use. If you have any additional comments or concerns, please feel free to contact us.
[Organization/Healthcare Provider Name and Contact Information]
Not at all likely | Extremely likely |
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
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