Intoxication Consent Assessment Questionnaire Form
Please complete this assessment to help us evaluate your current state and understanding regarding intoxication-related activities. This form is for general screening purposes only and does not collect sensitive health data.
Are you aware of the purpose of this assessment?
*
Yes, I understand the purpose
No, I am unsure
How would you rate your current level of alertness?
*
1
2
3
4
5
Please indicate your agreement with the following statement: "I feel capable of making informed decisions at this moment."
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Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Have you consumed any substances (alcohol or otherwise) in the last 6 hours?
*
Yes
No
Prefer not to say
Please select any symptoms you are currently experiencing.
*
Drowsiness
Slurred speech
Impaired coordination
Nausea
None of the above
Please indicate your level of agreement with each statement below.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am aware of my surroundings
1
2
3
4
5
I am able to follow instructions
6
7
8
9
10
I feel physically steady
11
12
13
14
15
I can communicate clearly
16
17
18
19
20
How confident are you in your ability to recall recent events?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Do you understand the potential risks associated with intoxication?
*
Yes, I fully understand
Somewhat
No, I do not understand
In your own words, please describe your current state or any concerns you may have.
*
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Should be Empty: