Alcohol Risk Assessment Form
Use this form to review alcohol-use patterns and related impacts so a risk level can be identified.
Assessment Details
Full Name
*
First Name
Last Name
Age Group
*
Under 18
18-24
25-34
35-44
45-54
55+
Contact Email for Follow-Up
example@example.com
Current Role / Relationship to Drinking Pattern Context
Please Select
Self
Parent/Guardian
Partner/Spouse
Family Member
Friend
Healthcare Professional
Employer/Workplace Representative
Other
Alcohol Use Screening
Frequency of alcohol use
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
Typical number of drinks on a drinking day
*
Please Select
1-2
3-4
5-6
7-9
10+
How often more than 6 drinks are consumed on one occasion
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Have there been concerns from others or issues related to drinking?
*
No
Yes, concerns from others
Yes, personal or family issues
Yes, both
Impact and Follow-up
How has alcohol use affected you?
*
Rows
No impact
Mild impact
Moderate impact
Severe impact
Sleep
1
2
3
4
Work or study
5
6
7
8
Mood
9
10
11
12
Relationships
13
14
15
16
Additional comments and preferred follow-up
Submit Assessment
Should be Empty: