Mental Health and Substance Abuse Awareness Committee - Alcohol Use Wellness Check and Screening

Alcohol Use

Check the box that best describes your answer for the period covering the past 12 months

1. How often do you have a drink containing alcohol?
Never	Monthly or less	2 or 4 times a month	2 days a week	3 days a week	4 days a week	5 days a week	6 days a week	7 days a week

2. How many drinks* containing alcohol do you have on a typical day when you are drinking? * A standard drink is one 12 ounce bottle of beer or wine cooler, one 6 ounce glass of wine or 1.5 ounces of liquor.
None	1	2	3	4	5	6	7	8	9	10	11	12+

3. For women: How often do you have 4 or more drinks a day? For men: How often do you have 5 or more drinks a day?
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 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 a 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 a friend or a 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

11. Are you taking any medication (over the counter or prescription)?
Yes
No
If yes, have you been told by your doctor or pharmacist that alcohol may interact with one of your current medications (over the counter or prescription)?
Yes
No

12. At any time in his/her life has your father, mother, sister or brother ever been an alcoholic or problem drinker?
Yes
No

13. For women: Are you pregnant, breastfeeding or planning a pregnancy?
Yes
No

14. Alcohol Treatment History:
(check all that apply)
I am currently being treated for an alcohol problem
I was treated in the past for an alcohol problem
I have never been treated for an alcohol problem

15. Are you taking any medication (over the counter or prescription)?
Yes
No

16. Do you have a medical or mental health condition?
Yes
No

17. Age:	18. Sex: Male Female
19. Race:	20. County of residence:
21. Zip Code	22. Income:

This screening is for educational and informational purposes only. All information on this site is confidential. This is not a substitute for a diagnosis for mental illness. A diagnosis for mental illness can only be made by a clinical evaluation from a healthcare professional.

The screening questionnaire on the Guide to Feeling Better website is solely for the purpose of identifying symptoms.
Guide to Feeling Better is not responsible for clinical diagnosis or treatment procedures of any individuals listed on the Guide to Feeling Better resource page.
These nationally accepted and reliable research-based questionnaires will help you determine if further follow-up with your doctor is necessary. They are not meant to take the place of a professional evaluation.