| Personalised Alcohol Use Feedback
These questions refer to your use of alcohol. Answer the 21 questions listed below and we will give you a personalized feedback report about your drinking.
Your responses are anonymous, and this service is free.
Please click, or type in where appropriate, the answer that is correct for you. Once you have finished putting in your answers, click the "submit" button at the bottom of the questionnaire and we will return a web page with your personalized feedback report within a few moments.
 How often do you have a drink containing alcohol? |
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 How many drinks containing alcohol do you have on a typical day when you drink? |
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 How often do you have six or more drinks on one occasion? |
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 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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 How often during the last year have you failed to do what was normally expected from you because of drinking? |
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 How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session? |
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 How often during the last year have you had a feeling of guilt or remorse after drinking? |
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 How often during the last year have you been unable to remember what happened the night before because you had been drinking? |
Never
Less than monthly
Monthly
Weekly
Daily or almost daily |
 Have you or someone else been injured as a result of your drinking? |
No
Yes - but not in the last year
Yes - during the last year |
 Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down? |
No
Yes - but not in the last year
Yes - during the last year |
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 What was your drinking like during a typical week in the last year?
We realize this will only be a rough estimate, but please indicate the number of drinks you usually drank on each day of the week in the boxes below.
(One 'drink' is the equivalent of:
- One 12-ounce bottle of beer or wine cooler, OR
- One 5-ounce glass of wine, OR
- 1.5 ounces of 80-proof distilled liquor (vodka, scotch etc.))
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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 In the past year, was there ever a time that you felt your alcohol use had a harmful effect on your friendships or social life?
No
Yes |
 In the past year, was there ever a time that you felt your alcohol use had a harmful effect on your physical health? |
No
Yes |
 In the past year, was there ever a time that you felt your alcohol use had a harmful effect on your outlook on life (happiness)? |
No
Yes |
 In the past year, was there ever a time that you felt your alcohol use had a harmful effect on your home life or marriage? |
No
Yes |
 In the past year, was there ever a time that you felt your alcohol use had a harmful effect on your work, studies, or employment opportunities? |
No
Yes |
 In the past year, was there ever a time that you felt your alcohol use had a harmful effect on your financial position? |
No
Yes |
 To see where you fit in on a graph of drinking patterns, please tell us a little about yourself: |
 How old are you?
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 Are you male or female?
Male
Female |
 What country do you live in?
Canada
USA
Other
If other, please type the country name.
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 How much do you weigh?
(lbs.)
(kgs.) |
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