Alcohol Use Self-Assessment
Reflect on your alcohol consumption habits and patterns by completing this confidential self-assessment.
Full Name
First Name
Last Name
Age
*
Gender
Male
Female
Non-binary
Prefer not to say
How often do you have a drink containing alcohol?
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
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 or more
How often do you have six or more drinks on one occasion?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
In the past year, how often have you found you were not able to stop drinking once you had started?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Alcohol Use Impact Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
Have you failed to do what was normally expected of you because of drinking?
1
2
3
4
5
Have you needed a first drink in the morning to get yourself going after a heavy drinking session?
6
7
8
9
10
Have you felt guilt or remorse after drinking?
11
12
13
14
15
Have you been unable to remember what happened the night before because of your drinking?
16
17
18
19
20
Has a relative, friend, or health professional expressed concern about your drinking or suggested you cut down?
21
22
23
24
25
On a scale from 1 to 10, how would you rate your concern about your own drinking habits? (1 = Not concerned, 10 = Extremely concerned)
*
Not concerned
1
2
3
4
5
6
7
8
9
Extremely concerned
10
1 is Not concerned, 10 is Extremely concerned
Have you ever tried to cut down or stop drinking?
*
Yes
No
If yes, what strategies have you used? (Select all that apply)
Seeking support from friends or family
Talking to a health professional
Attending a support group
Setting personal limits
Other
Would you like to receive information or resources about reducing alcohol use?
*
Yes
No
Submit Assessment
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