Alcohol Self Screening Test Gender Male Female Age Select 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 Ethnicity Select Asian African Caucasian Hispanic Other population groups Answer all the questions: How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 or 3 times a week 4 or more times a week How many 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 How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you found that you were unable to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Monthly or less 2 to 4 times a month 2 or 3 times a week 4 or more times a week How often during the last year have you had a feeling of guilt or remorse after drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 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 Have you or someone else been injured as the result of your drinking? Never Yes, but not in the last year Yes, during the last year Has a relative, friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? Never Yes, but not in the last year Yes, during the last year
