First Name:    

Last Name:    

Date of Birth:  

PATIENT: Beacuse alcohol use can effect your health and can interfere with certian medications and treatments, it is important that we ask some questions about your use of alcohol.  Your answers will remain confidential so please be honest. Select the line that best describes your answer to each question.

1. How often do you have a drink containing alcohol?
   Never
   Monthly or less
   2 to 4 times a month
   2 to 3 times a week
   4 or more times a week
   
2. How many standard drinks containing alcohol do you have on a typical day when you are drinking?
   1 or 2
   3 or 4
   5 or 6
   7 to 9
   10 or more
   
3. 3. How often do you have 6 or more standard drinks on one occasion?
   Never
   Less than monthly
   Monthly
   Weekly
   Daily or almost daily
   
4. How often during the last year have you found that you were not able to stop drinking once you had started?
   Never
   Less than monthly
   Monthly
   Weekly
   Daily or almost daily
   
5. How often during the last year have you failed to do what was normally expected from you because of your drinking?
   Never
   Less than monthly
   Monthly
   Weekly
   Daily or almost daily
   
6. How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
   Never
   Less than monthly
   Monthly
   Weekly
   Daily or almost daily
   
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
   Never
   Less than monthly
   Monthly
   Weekly
   Daily or almost daily
   
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
   Never
   Less than monthly
   Monthly
   Weekly
   Daily or almost daily
   
9. Have you or someone else been injured as a result of your drinking?
   No
   Yes, but not in the last year
   Yes, during the last year
   
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?
    No
    Yes, but not in the last year
    Yes, during the last year