Alcohol Use Survey
Answers marked with a * are required.
Problem Alchol Use Assessment
This survey is 100% Confidential. ONLY Dr. Rodman will see your responses and contact information.
How often do you have a drink containing alcohol?
*
Never
2-4 times a month
4 or more times a week
2-3 times a week
Monthly or less
How many drinks containing alcohol do you have on a typical day when you are drinking?
*
1-2
3-4
5-6
7-9
10+
How often do you have 6 or more drinks on one occasion?
*
Never
2-4 times a month
4 or more times a week
Monthly or less
2-3 times a week
After a night of drinking, how often do you not remember a part of the evening?
*
Never
4 or more times a week
Monthly or less
2-4 times a month
2-3 times a week
How often during the last year have you failed to do what was normally expected of you because of drinking?
*
Never
4 or more times a week
Monthly or less
2-3 times a week
2-4 times a month
How often in the last year have you found you were not able to stop drinking alcohol?
*
2-4 times a month
2-3 times a week
Never
4 or more times a week
Monthly or less
Problematic Usage: How often do you feel guilty about drinking?
*
4 or more times a week
Monthly or less
Never
2-3 times a week
2-4 times a month
Has a doctor or health worker been concerned about your drinking or suggested you cut down?
*
Yes, during the last year
No
Yes, but not in the last year
Have you or someone else been injured as a result of drinking?
*
No
Yes, during the last year
Yes, but not in the last year
How often do you drink before noon?
*
Never
Monthly or less
4 or more times a week
2-3 times a week
2-4 times a month
Once you have answered all of the questions, please enter your contact information and click submit. Dr. Rodman will contact you personally to discuss your results.
*
First Name:
Email:
Phone:
Age:
Gender:
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