Alcohol Consumption Survey
Age
Please Select
Less than 18
18-29
30-39
40-49
50-60
60+
Gender
Please Select
Female
Male
Ethnicity
Have you ever consumed alcohol?
Yes
No
At what age did you start consuming alcohol?
Why did you start consuming alcohol?
Peer Pressure
Curiosity
Bored
Influence of an adult
Other
Do you feel you are a normal drinker?
Yes
No
How often do you drink?
Everyday
3-5 times a week
Once a week
Only on weekends
On special occasions
Other
Do you engage in binge drinking? ( 5 or more drinks in a sitting)
Yes
No
In the last two weeks, how many times have you had 5 or more drinks at a sitting?
0
1-3
4-5
6-7
More than 7
Are you always able to stop drinking when you want to?
Yes
No
Have you ever passed out or experienced memory loss due to drinking?
Yes
No
Do you ever drive after drinking?
Yes
No
Do you drink to feel good/to function better?
Yes
No
Do you have a history of alcohol or drug problems in your family?
Yes
No
Have you ever become violent or aggravated while drinking?
Yes
No
Have you ever gotten into trouble at work because of drinking?
Yes
No
Submit
Should be Empty: