Daily Alcohol Intake Self-Assessment Form

Daily Alcohol Intake Self-Assessment Form
Reflect on your daily alcohol consumption habits and related behaviors. Your responses are confidential and intended for personal awareness.
Your Full Name
First NameLast Name
Your Age
Gender
Other
On average, how many alcoholic drinks do you consume per day? (1 drink = 12 oz beer, 5 oz wine, or 1.5 oz spirits)
What types of alcoholic beverages do you typically consume?
Other
Alcohol Consumption Patterns
Rows Never Rarely Sometimes Often Always
I drink alcohol with meals
I drink alcohol alone
I drink alcohol in social settings
I drink alcohol to relax or relieve stress
At what time of day do you usually consume alcohol?
How often do you experience the following after drinking?
Rows Never Rarely Sometimes Often Always
Hangovers
Memory lapses
Difficulty sleeping
Feeling anxious or depressed
How would you rate your current level of concern about your alcohol intake?

1
2
3
4
5
6
7
8
9
10
1 is Not concerned, 10 is Very concerned
Have you considered reducing your alcohol consumption?
If you wish, briefly describe any specific concerns or goals related to your alcohol use.
Should be Empty:

Select theme:

Rows	Never	Rarely	Sometimes	Often	Always
I drink alcohol with meals
I drink alcohol alone
I drink alcohol in social settings
I drink alcohol to relax or relieve stress

Rows	Never	Rarely	Sometimes	Often	Always
Hangovers
Memory lapses
Difficulty sleeping
Feeling anxious or depressed