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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?
    Never
    Monthly or less
    2 to 4 times/month
    2 to 3 times/week
    4 or more times/week

How many drinks containing alcohol do you have on a typical day when you drink?
    1 or 2
    3 or 4
    5 or 6
    7 to 9
    10 or more

How often do you have six or more drinks on one occasion?
    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?
    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 from you because of drinking?
    Never
    Less than monthly
    Monthly
    Weekly
    Daily or almost daily

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?
    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?
    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 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

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


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?
Are you male or female?
Male
Female
What country do you live in?
Canada
USA
Other

If other, please type the country name.
How much do you weigh? (lbs.) (kgs.)