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How many times per week do you consume alcohol?
 
0
 
1-2
 
3-4
 
5+
 
 
 
On average, how many drinks do you consume per instance?
 
0
 
1-2
 
3-4
 
5+
 
 
 
What type of alcohol do you generally drink?
 
Beer
 
Wine
 
Hard Liquor
 
Mixed Drinks
 
None

 
 
 
Why do you generally drink?
 
Stress Relief
 
Social Participation
 
Sleep Aid
 
Coping Mechanism
 
I Don't Drink

 
 
 
Where do you generally drink?
 
Bars
 
Restaurants
 
Friends House
 
Your Home
 
I Don't Drink
 
Other
 
 
 
 
How many people do you generally drink with?
 
0
 
1-4
 
5-9
 
10+
 
I Don't Drink
 
 
 
Who do you generally drink with?
 
Family
 
Co-Workers
 
Friends
 
Alone
 
I Don't Drink
 
 
 
How often do you feel alcohol negatively impacts your life/ability to function?
 
Rarely (0-25%)
 
Semi-Frequently (25-50%)
 
Frequently (50-75%)
 
Very Frequently (75-100%)
 
 
 
Do you find it difficult to control your alcohol intake?
 
Yes
 
No
 
Other
 
 
 
 
What of the following have you done due to consuming alcohol?
 
Drinking and driving
 
Woke up in an unfamiliar location
 
Skipped class
 
Called into work
 
Missed a deadline
 
Cancelled plans
 
None
 
Other
 

 
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