Alcohol Assessment - QUESTIONNAIRE

Name

First

Last

1) Did your mother drink alcohol when you were a child? If so, how much? Was it ever a problem for her or you?

2) Did your father drink alcohol when you were a child? If so, how much? Was it ever a problem for him or you?

3) Did your siblings or other relatives drink alcohol when you were a child? If so, how much? Was it ever a problem for them or you?

4) Do you drink alcohol? If so how much?

5) How much do you spend on alcohol each week/month?

6) What is your first memory of alcohol?

7) What is your first memory of getting drunk?

8) What is one memory of something upsetting which resulted from you drinking too much alcohol?

9) What was your experience with alcohol and friends in high school?

10) Have you ever drunk to the point of throwing up and/or passing out? If so, when was the last time?

11) Have you felt remorse after drinking?

12) Do you crave a drink at a definite time daily?

13) Have you ever decided to stop drinking for a week or so, but only lasted for a couple of days?

14) Has a relative, a friend, a doctor, or another health professional been concerned about your drinking or suggested you cut down? If so who, when?

15) Have you ever felt that your life would be better if you did not drink alcohol?

Please add anything else you feel is relevant regarding your life and alcohol.

Well done!