Daily Drinking Questionnaire
Your responses will help us understand your drinking habits and provide personalized recommendations.
Personal Information
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Male
Female
Other
Age
Drinking Habits
How often do you consume alcoholic beverages?
Daily
3-4 times a week
1-2 times a week
Occasionally
Rarely
How many standard drinks do you consume on a typical drinking day?
Do you have a history of alcohol abuse or dependence?
Yes
No
Have you ever experienced negative consequences due to alcohol consumption?
Yes
No
Do you have a family history of alcoholism?
Yes
No
Additional Comments
Submit
Should be Empty: