Ethanol Effects Assessment
Please complete this assessment regarding your experience and perceptions related to ethanol (alcohol) consumption. Your responses are confidential and will be used for research and evaluation purposes.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
How often do you consume ethanol-containing beverages (such as beer, wine, or spirits)?
*
Never
Rarely (less than once a month)
Occasionally (1-3 times a month)
Regularly (once a week or more)
On average, how many standard drinks do you consume per occasion?
*
1-2
3-4
5-6
More than 6
I do not drink
Please indicate the extent to which you have experienced the following effects after consuming ethanol-containing beverages:
*
Rows
Never
Rarely
Sometimes
Often
Always
Relaxation
1
2
3
4
5
Euphoria
6
7
8
9
10
Impaired coordination
11
12
13
14
15
Nausea
16
17
18
19
20
Headache
21
22
23
24
25
Drowsiness
26
27
28
29
30
Mood swings
31
32
33
34
35
How would you rate the overall impact of ethanol on your mood?
*
Very negative
1
2
3
4
5
6
Very positive
7
1 is Very negative, 7 is Very positive
Have you ever experienced any of the following after consuming ethanol? Select all that apply.
Blackouts or memory loss
Difficulty concentrating
Increased sociability
Aggressive behavior
No noticeable effects
Other
Please rate the severity of any negative effects you have experienced after consuming ethanol.
1
2
3
4
5
Please provide any additional comments about your experiences or perceptions regarding ethanol (optional).
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