Please place an X in the square with the answer for each question that is correct for you. Remember, one drink equals one 12-ounce beer, one 5-ounce glass of wine, or a 1.5-ounce shot of 80 proof liquor.
| |
0 |
1 |
2 |
3 |
4 |
|
- 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 |
|
- 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 |
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- How often do you have six or more drinks on one occasion?
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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?
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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?
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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 |
|
- Have you or someone else been injured because of your drinking?
|
No |
|
Yes, but not in the last year |
|
Yes, but not in the last year |
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- Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
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No |
|
Yes, but not in the last year |
|
Yes, but not in the last year |
|
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Total
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