Fatigue and Alcohol Assessment
Please complete this assessment to evaluate your recent fatigue levels and alcohol consumption. Your responses will help identify any potential risks related to fatigue and alcohol use.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How often do you consume alcoholic beverages?
*
Never
Once a month or less
2-4 times a month
2-3 times a week
4 or more times a week
How many standard drinks did you consume in the past 24 hours? (One standard drink = 12 oz beer, 5 oz wine, or 1.5 oz spirits)
*
When did you last consume alcohol?
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
How many hours did you sleep in the past 24 hours?
*
Rate your current level of fatigue
*
Not fatigued
1
2
3
4
5
6
7
8
9
Extremely fatigued
10
1 is Not fatigued, 10 is Extremely fatigued
In the past week, how often have you experienced the following?
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty concentrating
1
2
3
4
5
Falling asleep unintentionally
6
7
8
9
10
Reduced work performance
11
12
13
14
15
Irritability or mood changes
16
17
18
19
20
Memory lapses
21
22
23
24
25
Have you engaged in any of the following activities in the past 24 hours? (Select all that apply)
*
Driving a vehicle
Operating machinery
Caring for dependents
Attending work or school
None of the above
Other
Do you believe your fatigue or alcohol consumption has negatively affected your performance or safety in the past week?
*
Yes
No
Not sure
Additional comments or concerns (optional)
Submit Assessment
Should be Empty: