For the following questions, check the box that comes closest to your answer:
1. How often do you have a drink containing alcohol?
Never
Monthly
Weekly
2-3 times a week
4-7 times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
0
1 or 2
3 or 4
5 or 6
7 or 8
10 or more
3. How many times in last year have you found yourself not remembering portions of what happened the night before because of your drinking?
1-3
4-6
7-9
4. How many times in the past year have you found yourself having difficulty stopping your drinking once you started?
5. How many times in the past year have you felt guilty as a result of your drinking?
6. How many times in the past year have you injured yourself as a result of drinking?
7. In the past year, has a relative, friend, doctor or other health care professional been concerned about your drinking?
No
Yes
8. In the past year have you consumed alcohol while taking medications (i.e. birth control, anti-depressants, etc.)?
