Your name
Phone number
Email address
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 standard 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
How often do you have 6 or more standard drinks on one occasion?
never
less than monthly
monthly
weekly
daily or almost daily
How often during the last year have you found yourself unable to stop drinking once you had started?
never
less than monthly
monthly
weekly
daily or almost daily
How often in the past year have you failed to do what is normally expected of you because of your drinking?
never
less than monthly
monthly
weekly
daily or almost daily
How often in the last year have you needed an alcoholic 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 past year have you felt guilty or remorseful after drinking?
never
less than monthly
monthly
weekly
daily or almost daily
How often in the past 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 as a result of your drinking?
no
yes, but not in the last year
yes, during the last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggest you cut down?
no
yes, but not in the last year
yes, during the last year
