1. How many times a week, on average, do you drink?
A) Less than 1
B) 1
C) 2
D) 3
E) 4 or more
2. When you do drink, how many drinks, on average, do you consume in
one evening?
A) 0
B) 1-2
C) 3-5
D) 6-9
E) 10 or more
3. For the last week please fill in all the bubbles that apply:
A) I have blacked out from drinking
B) Drinking has affected my relationship w/others
C) Drinking has affected my academics
D) I drank more than originally intended
E) None of the above
4. For the last week please fill in all the bubbles that apply:
A) I have refused alcohol
B) I have limited my number of drinks
C) I stayed in while my friends drank
D) I have avoided high risk situations-
E) None of the above regarding alcohol
Please read the following statements carefully. Each one describes a way that
you might (or might not) feel about your drinking. For each statement, fill
in one bubble from A to E, to indicate how much you agree or disagree with it
right now.